Every finding on record at Wayne Health Care

Based on observations, interviews, and record review conducted during a Recertification Survey from 09/09/2024 to 09/13/2024, for one (Resident #154) of six residents reviewed for behaviors, the facility could not provide evidence that a thorough investigation was completed to ensure the resident's safety following a potential elopement incident. Specifically, Resident #154, who was identified as at risk for elopement and wore a wander guard bracelet (a wander management system which uses bracelets, sensors, and technology to alert staff when a resident tries to leave a safe area), was found outside without their wander guard bracelet on. Additionally, several days prior, Resident #154 was found without their wander guard bracelet on, stating it had fallen off. The facility could not provide evidence that thorough investigations were conducted to determine how the resident's wander guard came off in both instances. This is evidenced by the following: The facility policy Event Accident Investigation Reporting Guidelines, dated reviewed April 2023, included that all events, accidents, unusual occurrences, and near-misses that occurred would be investigated in a timely manner and residents would receive prompt and adequate treatment. Every effort would be made to determine the cause of each accident and/or event and measures would be put into place to prevent reoccurrence. Resident #154 has diagnoses that included stroke, seizures, and dementia. The Minimum Data Set Resident Assessment, dated 08/28/2024, revealed Resident #154 was cognitively intact. Review of the Comprehensive Care Plan revealed Resident #154 was at risk for wandering. Interventions included monitoring the resident's attempts to leave the unit or facility, and a wander guard bracelet provided to alert the facility of wandering and/or elopement. Review of Resident #154's Care Card (care plan used for Certified Nursing Assistants for daily care) included the resident was independent with ambulation, an elopement risk, and wore a wander guard bracelet on the ankle. Review of Resident #154's electronic medical record revealed the following: a. In a nursing progress note, dated 08/25/2024, Licensed Practical Nurse #1 documented that the wander guard (system) was activated while maintenance was taking out the garbage. While checking all residents to ensure their wander guard bracelets were on (the residents), Resident #154 was not wearing their wander guard bracelet. Resident #154 said it had fallen off and a new wander guard was placed to Resident #154's left ankle. b. In a nursing progress note, dated 08/31/2024 at 9:31 PM, Licensed Practical Nurse #2 documented that Resident #154 was found sitting outside in front of the building (no wander guard alert had been activated). The resident said they had taken their wander guard bracelet off with a pen. A new wander guard bracelet was placed. The facility could not provide documented evidence that any investigation had been conducted to determine how Resident #154's wander guard bracelet had been removed on either instance. During an interview on 09/09/2024 at 10:17 AM, Resident #154 stated that they had recently removed their bracelet (wander guard) because they wanted to go outside. During an observation and interview on 09/12/2024 at 4:09 PM, Resident #154 was wearing a wander guard bracelet. When asked how they had previously removed their wander guard bracelet, Resident #154 said they took a pair of scissors from behind the nurses' desk and cut it off. On 09/12/2024, the facility identified that a second resident had removed their wander guard twice with a pair of scissors found in their room. The incident remained under investigation by the facility. During an interview on 09/13/2024 at 10:24 AM, Registered Nurse Clinical Leader #3 said wander guards may be applied to residents who are identified to be at high risk for elopement, if they have tried to leave the facility, or if they have made statements about leaving. Registered Nurse Clinical Leader #3 stated the nurses check every shift that the wander guard is on the resident and document it in the resident's electronic medical record. If a resident was found to not have their wander guard on, staff should try to figure out where it was and put on a new one if not found. Registered Nurse Clinical Leader #3 said finding a resident without their wander guard on should prompt an investigation to determine how it got off. During an interview on 09/13/2024 at 10:44 AM, Registered Nurse Manager #2 said if a resident were found not wearing their wander guard bracelet, and they were still on the unit, they would probably not initiate an incident report, but they would ask staff how the resident got it off. Registered Nurse Manager #2 stated residents should not be able to get the wander guard bracelet off. Registered Nurse Manager #2 said an investigation was not conducted to determine how the resident's wander guard bracelet came off when discovered on 08/25/2024 or 08/31/2024 because the resident said they took it off with a pen. Registered Nurse Manager #2 said the 08/31/2024 event was an incident that required increased monitoring and interventions. During an interview on 09/13/2024 at 11:21 AM, the Director of Nursing said if a resident was found without their wander guard bracelet on, staff should determine how it came off and reapply the wander guard if appropriate. The Director of Nursing stated there are no instances in which a resident's wander guard should be off without staff's knowledge. The Director of Nursing said they would have expected an investigation conducted to determine how Resident #154's wander guard bracelet was removed on 08/25/2024 and 08/31/2024 (to prevent reoccurance). 10 NYCRR 415.12(h)(2)

Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY 405), completed 5/23/22, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for two (Residents #150 and #152) of eight residents reviewed for accidents. Specifically, Resident # 150 was identified as a smoker when admitted [DATE]. Resident has a BIMS (Brief Interview of Mental Status) of 15 (out of 15). The Comprehensive Care Plan (CCP), dated 3/18/21, included the resident was non-compliant with facility smoking policy, had a history of declining smoking blanket and gloves as recommended by therapy and was supposed to sign out at nurse's station to go off property when smoking and smoking materials to be kept in the medication room. Incident/Accident (I/A) Report 1/27/22, identified [CONDITION(S)] on resident's fingers related to smoking and Occupational Therapy (OT) assessment at this time revealed the Resident was observed holding the cigarette too close to the blanket and clothing and suggested an ash tray for the cup holder on chair. The 3/30/22 OT assessment recommended use of a fire blanket due to hot ashes falling into resident lap creating holes. OT deemed no therapy needed at this time. (No new interventions were recommended). Both Smoking Assessments, dated 1/27/22 and 3/23/22 included risk scores of zero. An I/A report documented that on 4/6/22 the resident was noted to have three blisters to the right hand that resident reported were [CONDITION(S)] from their cigarettes. On 4/19/22 the resident was seen in the emergency department (ED) and documented significant [CONDITION(S)] to both hands from smoking and was started on antibiotics. Resident #150 was observed on 5/19/22 at 8:20 am exiting the facility via the front door in a motorized wheelchair, proceeded down the driveway, around a corner to a paved area (approximately 40 yards from building) and was observed smoking. Resident had a grey blanket and mesh glove to the right hand. Glove noted to have holes in web area of index and middle finger and a burn hole was noted on the lap blanket. The resident stated he/she had burned the blanket to see if it was fire retardant. When ask where they disposed of the cigarette butts, the resident stated he/she had their own ash tray in the cup holder of the chair. The resident stated they empty the ash tray in the garbage can by the front door and/or in their room trash bin, none of which are observed to be fire retardant receptacles. Resident #152 reported they were unable to extinguish their cigarettes, allowing them to burn out in the ashtray and disposed of them in the trash can in their room. This resulted in immediate jeopardy with the likelihood for serious harm to Resident health and safety and is Substandard Quality of Care. This is evidenced by the following: The facility policy Smoke Free Work Environment, dated 5/1/19, included smoking or tobacco use is prohibited on the grounds within 15 feet of respective property line. Current nursing home residents who smoke will be able to continue smoking in a designated area 30 feet from the building. New residents must abide by our smoke-free policy. The policy did not include information related to storage of residents smoking materials or requirement for residents to sign out of the facility to smoke. 1.Resident #150 was admitted [DATE] with diagnoses that included diabetes, [CONDITION(S)] with hemodialysis and was a chronic smoker. The Minimum Data Set (MDS) Assessment, dated 5/6/22, revealed the resident was cognitively intact. A Smoking Policy Acknowledgement, dated 3/18/21, signed by Resident #150 and approved by Occupational Therapy (OT), documented that Resident #150 smoked and would comply with the facility policy or agree to transfer to another facility that allows smoking. The current CCP and Certified Nursing Assistant (CNA) Care Card included that Resident #150 was independent in a motorized wheelchair outside on facility property and was noncompliant with the facility smoking policy. The CCP included the resident was at risk for [CONDITION(S)] related to smoking and that staff should encourage Resident #150 in use of a smoking apron, a burn blanket, fire- proof glove and a cigarette holder when going outside to smoke. Interventions also included to sign out at the nurses' station when going off property to smoke and that their smoking materials should be kept in the medication room or in a locked drawer in their room. A nursing progress note and an I/A Report both dated 1/27/22, documented that Resident #150 had 3 small brown circular areas on their right middle finger. Resident #150 had reported they were [CONDITION(S)] from their cigarette. The medical provider and Director of Nursing (DON) were notified, and an OT referral ordered to evaluate the resident's smoking ability. There was no documented evidence in Resident #150's Electronic Medical Record (EMR) that the resident was assessed by a medical provider following the 1/27/22 incident. An OT evaluation, dated 2/1/22, documented that Resident #150 had burned their hands and clothing while smoking due to difficulties with fine motor coordination that was needed to safely hold a cigarette. Resident #150 agreed to trial safety equipment (cigarette holder) to assist in increasing safety with smoking. OT treatment documentation from 2/1/22 to 2/14/22 documented that Resident #150 had difficulties managing a cigarette holder, continued to forget to hold burning cigarettes away from blanket and clothes and brought cigarette butts into the facility on the blanket in their lap or in their pants pocket. The OT discharge note dated 2/14/22, documented that Resident #150 did consistently use an ashtray in a cup holder and had no new burn marks noted on the blanket or gloves. Tobacco Screen and Safety assessments dated 1/27/22 and 3/23/22, documented a risk score for Resident #150 as zero. The assessments did not include a history of noncompliance with facility smoking policy or a history of [CONDITION(S)] from smoking. An OT note dated 3/30/22, documented that a referral was again made by nursing due to decreased safety with smoking. The OT note documented that therapy was not necessary at that time and that Resident #150 had agreed to use the fire blanket due to hot ashes falling on their blanket and burning small holes. A nursing progress note and I/A Report both dated 4/6/22, documented a large hole was observed in Resident #150's lap blanket. The resident stated that the hole was from their cigarette. Three blisters were observed on the resident's right index finger and one blister on the right second finger. Resident #150 was re-offered a smoking apron which was accepted, and a new blanket was ordered. The I/A Report documented that the resident's CCP and CNA Care Card were updated, and the medical provider was made aware. There was no documented evidence in Resident #150's EMR that the resident was assessed by a medical provider following the 4/6/22 incident until 4/18/22. In a medical progress note dated 4/18/22, Physician Assistant (PA) #1 documented that the mobile surgical team was consulted for management of [CONDITION(S)] to Resident #150's right hand. A description of the burn wounds included multiple [CONDITION(S)] of various stages to the second and third fingers on the right hand in various stages of healing with pus and serous (clear or slightly yellow plasma) drainage with burn tissue noted. The treatment plan included cleansing the wounds, applying [MEDICATION(S)] cream (a sulfa antibiotic used to prevent and treat infections with [CONDITION(S)]), a non-stick dressing cover and wrapping with gauze. Additionally, oral antibiotics were ordered for 10 days. The PA documented a concern that if Resident #150 continued to smoke and a cigarette dropped that the gauze wrap would catch on fire. The PA documented that staff were aware of the concerns and were working with the resident on safer practices and smoking cessation. There was no documented evidence in the resident's EMR that smoking cessation products had been attempted. In a medical progress note dated 4/19/22, Nurse Practitioner (NP) #1 documented that Resident #150 had new onset upper extremity unpredictable tremors, lethargy, and had missed a [CONDITION(S)] treatment. NP #1 recommended transfer to the hospital to evaluate for [CONDITION(S)] (serious infection of the blood stream). An ED visit note, dated 4/19/22, documented that Resident #150 had significant [CONDITION(S)] on both hands secondary to [CONDITION(S)] from smoking and [CONDITION(S)] (an infection in the tissues). [CONDITION(S)] was ruled out and recommendations were to continue antibiotics and wound treatments. OT daily treatment notes dated 5/1/22 to 5/7/22, documented that Resident #150 complained the fire gloves were too tight and the Occupational Therapist cut web space on gloves. Resident #150 stated at the time that they were going to test the gloves to see if they burn. The note documented that the therapist informed the resident they would be deemed unsafe to smoke if they continued to purposely burn items. On 5/3/22 OT documented that that there were scorch marks noted on the resident's gloves over their bandaged fingers and on 5/5/22 new gloves were provided. During an observation on 5/19/22 at 8:20 a.m., Resident #150 exited the facility via the main entrance in a motorized wheelchair, proceeded down a driveway and around the corner to a paved area approximately 60 feet from the facility building and was then observed smoking a cigarette. Resident #150 was wearing a gray blanket (noted to have a burn hole in it) over the lap and a mesh glove (also noted with holes in it) on their right hand. During an immediate interview, Resident #150 stated that they had burned the blanket to see if it was fire retardant. The resident stated they would not wear the blanket when it was 90 degrees out and when asked where they disposed of cigarette butts, Resident #150 stated they had their own ash tray in the cup holder which they emptied in the garbage can by the main entrance or in their room. Observations of the main entrance garbage can on 5/19/22 at approximately 8:20 a.m. and Resident #150's room garbage can on 5/19/22 at 10:10 a.m., revealed neither garbage cans were fire retardant receptacles. 2.Resident #152 was admitted to the facility 12/31/20 with diagnoses that included depression and [CONDITION(S)]. The MDS assessment dated [DATE], documented the resident was cognitively intact. The current CCP and CNA Care Card documented that Resident #152 was noncompliant with the facility smoking policy. Interventions included smoking assessments completed, that the resident may go outside with family/friends to smoke, must wear a smoking blanket/apron, use a bean bag ash tray and that the resident may keep their own smoking materials. During an interview on 5/18/22 at 3:12 p.m. Licensed Practical Nurse (LPN) #1 stated there were several residents on the unit, including Resident #150 and #152 (roommates) who smoked. LPN#1 stated the residents typically let them know when they were leaving the unit and any protective equipment should be on their care plans which staff should ensure the residents utilizes. LPN #1 stated that residents must ask for smoking materials which are kept in the medication room. When interviewed on 5/18/22 at 3:17 p.m. The Registered Nurse (RN)/Clinical Lead stated Residents #150 and #152 were alert and oriented and had smoking assessments completed quarterly or if any changes. The RN/Clinical Lead stated some residents are allowed to keep their own smoking materials and go out to smoke independently but are supposed to sign out. The RN/Clinical Lead stated Resident #150 had a noncompliant care plan and all they can do was encourage the use of safety equipment. The RN also stated Resident #150 and #152 both had locked drawers in their room for their smoking materials. During an observation on 5/19/22 at 10:28 a.m. Resident #152 entered the resident unit in a motorized wheelchair. The resident had a smoking blanket across their lap and bean bag ash tray sitting on it that contained multiple cigarette butts burned to the filters and one with fresh ashes on it. During an immediate interview, Resident #152 stated that they were unable to extinguish their cigarettes without burning their fingers. The resident stated they have staff empty the ash tray in the garbage can in their room. Resident #152 stated they use to turn in their smoking materials to staff but then found out that other residents were allowed to keep their smoking materials, so they informed staff they were now keeping theirs. In an observation on 5/19/22 at 10:10 a.m., of Resident #150 and #152's room, no locked drawers were present. During an interview on 5/18/22 at 3:33 p.m., with the Director of Nursing (DON) and the Administrator and again on 5/23/22 at 8:04 a.m., with the DON, the DON stated that all staff are responsible for ensuring that resident's CCPs are followed. Regarding Resident #150, the DON stated that the resident has had smoking assessments completed by nursing and therapy and had been educated on the risk. Resident #150 was deemed competent and aware of the risks and staff encourage the resident to follow the recommendations (cigarette holder, apron, blanket, gloves). The DON stated that if a resident passed a smoking assessment, they were allowed to keep their own smoking materials and added that they did not have a policy related to the smoking assessment. The Administrator stated that the facility has taken many measures to ensure resident safety and is unsure what more could be done without violating the resident's rights. During an interview on 5/19/22 at 8:33 a.m., with the Administrator, Vice President (VP) of Operations, and the Medical Director, the VP of Operations stated that the facility encourages residents to sign out and provide supervision as possible however residents make some decisions on their own. The VP of Operations stated the facility is a nonsmoking facility, but they do provide containers outside for used smoking materials. The VP of Operations stated the residents are reminded and encouraged to follow their plan of care however they have a right to refuse. The VP stated residents have a right to keep personal property including smoking materials. The Administer, the VP of Operations and the Medical Director stated they were all unaware of where residents disposed of cigarette butts/ashes. The Medical Director stated if a resident can understand the risks and are competent it is their right to smoke and refuse treatment. On 5/19/22 at 6:30p.m. the survey team declared that the IJ was removed based on the following corrective actions taken by the facility: a. Beginning 5/19/22, the facility will provide staff supervision for all residents who smoke. The facility provided buckets of sand outdoors for cigarette butt disposal and the social work department educated staff and all the residents who smoke regarding the use of the buckets. b. The policy and procedure for smoking assessments will be reviewed and revised and staff provided education. 10NYCRR 415.12(h)(1)(2)

Based on observations, interviews, and record reviews conducted during a Recertification Survey completed on 5/23/22, it was determined that for one (Resident #121) of three residents reviewed the facility did not ensure that each resident was provided with sufficient fluid intake to maintain proper hydration and health. Specifically, Resident #121 did not receive free water flushes (FWF) via their feeding tube (a tube inserted directly into the stomach in order to receive nutrients and fluids) as ordered by the physician. Additionally, there was no documented evidence that the resident's twenty-four-hour intake of FWF was being consistently monitored or documented to ensure appropriate amounts of fluids were administered. The findings are: The February 2019 facility policy Enteral Feeding - Care and Maintenance, included that the nurse will record amount of nutrient and water given in the Electronic Medical Record (EMR) every shift. The nurse will verify per provider order which should state the type of feeding, the rate infused, the amount of water flush and water given with the medications. At the end of each shift, the nurse will verify via the pump that amounts infused match provider order. In addition, the nurse will calculate water infused plus feeding infused and enter on the Intake and Output (I&O) flowsheet in the EMR. The policy also included that the Clinical Nurse Leader (CNL) would evaluate intake over twenty-four-hour periods and notify the provider if intake is out of parameters. Resident #121 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], revealed the resident was moderately impaired cognitively and received 51% or more of all calories and fluids via a feeding tube. The current Comprehensive Care Plan included to consult with dietary regarding tube feeds and administration of tube feeding as ordered by the medical provider. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .) with 140 mls of FWF every 4 hours (hrs.) (or 840 mls per day). During observations on 5/19/22 at 10:51 a.m., and 5/20/22 at 10:05 a.m., Resident #121's Diabetisource tube feed was infusing via a tube feeding pump as ordered and the FWF was infusing at 120 mls/4 hrs. (versus 140 mls/4 hrs. ordered). When observed on 5/19/22 at 10:51 a.m., the FWF bag of fluid was dated as hung 5/19/22 at 12:00 a.m., with 140 mls/4 hrs handwritten on the label. Review of the Intake/Output (I/O) flowsheet from 5/12/22 through 5/19/22 revealed that the FWF were documented at different times throughout each day from one to three times daily with amounts ranging from 320 mls to 1320 mls daily. In an interview on 5/20/22 at 11:01 a.m., Licensed Practical Nurse (LPN) #1 stated that at the end of each shift, the nurse is supposed to document the total amount of tube feed and FWF infused by the tube feed pump over the course of the shift and then the totals are cleared from the pump. LPN#1 reviewed the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . and stated that they were not sure why or how long the tube feed pump was programmed to administer 120 mls/4 hrs. instead of the ordered 140 mls/4 hrs. but that they would fix it. In an interview on 5/20/22 at 1:28 p.m. and again at 2:48 p.m., the Registered Dietician (RD) stated that Resident #121 should be receiving 140 mls/4hrs. The RD stated that nursing is expected to review and clear the feeding tube pump every shift. When asked about monitoring the 24 hr. totals, the RD stated that they do a quarterly assessment and that it is difficult to find the 24 hr. totals in the EMR. The RD stated they did not know if nursing was monitoring them or not. When interviewed on 5/20/22 at 2:54 p.m., the Registered Nurse (RN)/CNL stated the nurses are supposed to check the tube feed pump when hanging a new tube feed bag and are expected to clear the totals infused at the end of every shift. The RN/CNL did not think that anyone was performing 24 hr. intake checks. In an interview on 5/23/22 at 10:30 a.m., the Director of Nursing (DON) stated that whoever hangs the tube feed bag programs the tube feed settings into the pump. The DON stated that the FWF are administered as they are programmed into the pump and that the total volume is supposed to be checked at the end of each shift and documented on the I&O flowsheet. The DON stated that when administering medications, flushes of a specifically ordered volume are given before and after the administration of each medication, and the volumes are documented on the I/O flowsheet. The DON stated that if the nurse reviews the total intake amounts at the end of the shift and identifies that the resident didn't receive the required amount, the nurse is supposed to notify the off-shift director. 10NYCRR 415.12(j)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Neuro-Behavioral Unit) of three medication storage rooms reviewed, the facility did not provide pharmaceutical services to meet each resident's needs which includes: acquiring, receiving, dispensing, accurately administering or disposing of medications. The issues involved the improper disposal of a controlled substance and inconsistent documentation of narcotic reconciliation. This is evidenced by the following: Review of a facility policy, Medication Administration Controlled Substances, dated (MONTH) (YEAR), directs that single unit doses or partial doses remaining after the administration or attempted administration of a controlled substance may be destroyed on the unit. The actual disposal must be witnessed by a second medication qualified nurse, a pharmacist or a prescriber at the time of the disposal. A complete count of all controlled substances available on the nursing unit is done at each shift change. No nurse will leave the unit at the end of a shift until the narcotic count is complete and accurate. One nurse from the outgoing shift and one nurse from the incoming shift conduct the count and after completing the count both nurses will sign the inventory sheet. Observations and interviews conducted on 8/5/19 included the following: a. At 11:19 a.m., on the Neuro-Behavioral Unit, Licensed Practical Nurse (LPN) #1 was asked by the surveyor to open the narcotic box. LPN #1 opened the narcotic box and a clear medication cup containing a small volume of clear liquid was on the shelf. LPN #1 said that the medication was [MEDICATION NAME] ([MEDICATION NAME], used to treat severe acute or chronic pain). LPN #1 said the medication had to be locked in the narcotic box until someone could waste (dispose) it. LPN #1 said she watched another nurse prepare the medication and put the excess in the narcotic box. LPN #1 said because she had observed that, it was okay for her to waste the drug and she then poured it down the sink drain. When asked, LPN #1 said that two nurses should observe the wasting. Additionally, a review of the Narcotic Count and Key Log Sheet for 8/5/19, revealed there were no signatures for the morning shift count. When interviewed at that time, LPN #1 said she did not sign at the time of the count but would sign at that time. When asked, she said incoming and outgoing staff are to sign the sheet at the time of the count. b. At 11:28 a.m., the Assistant Director of Nursing (ADON) reviewed the Narcotic Count and Key Log Sheets, dated 8/1/19 through 8/5/19 and 7/1/19 through 7/31/19, and said there were multiple missing signatures (five for (MONTH) 2019 and 28 for (MONTH) 2019). The ADON said when counting narcotics, both the incoming and outgoing nurse must sign the sheet at the time of the count. She said two nurses must witness the disposal of a narcotic and then sign off. (10 NYCRR 415.18)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #50 and #18) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free of unnecessary medications. The issues included the lack of a gradual dose reduction for [MEDICAL CONDITION] medications or documentation of clinical contraindication and behaviors. This is evidenced by the following: Review of the facility policy and procedure [MEDICAL CONDITION] Medication, dated (MONTH) (YEAR), revealed that residents who use [MEDICAL CONDITION] drugs receive Gradual Dose Reductions (GDR) and behavioral interventions, unless clinically contraindicated. The documentation of the federally-mandated visit will include the rational for continued use or any changes in all [MEDICAL CONDITION] medications prescribed for the resident. 1. Resident #50 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/26/19, revealed the resident had moderately impaired cognition, no behaviors in the look back period, and received an antipsychotic medication. The Psychopharmacologic Drug Worksheet for Comprehensive Care, dated 3/18/19, included [MEDICATION NAME] (antidepressant)100 milligrams (mg) daily. The target behavior was depression and it was written in the comment section no taper. [MEDICATION NAME] 25 mg in the morning and 50 mg at bedtime. The target behaviors was dementia with behavior, and it was written in the comment section no GDR. The form does not include the date of the last GDR. The Neurological Nurse Practitioner Progress Notes, dated 7/18/19, revealed the resident has a primary [DIAGNOSES REDACTED]. The Consultant Pharmacist review, dated 7/18/19, includes the resident was last seen by psych in (MONTH) (YEAR) and no GDR was recommended. There has been no reference in the notes about his [MEDICAL CONDITION] except to say continue. Please consider documenting more concisely in the chart why a GDR was still not warranted. The physician progress notes [REDACTED]. The resident was stable on current regimen, and to continue [MEDICATION NAME] 25 mg each night. The resident does not tolerate tapering. The resident's depression was stable, continue [MEDICATION NAME] 100 mg daily. Review of the current Scheduled Medication Report, printed 8/1/19, included [MEDICATION NAME] 25 mg every morning and 50 mg at bedtime and [MEDICATION NAME] 100 mg daily. The current Comprehensive Care Plan revealed that the resident received [MEDICAL CONDITION] medications for depression and dementia with behavioral disturbance. Interventions included to monitor the medication and side effects, and if necessary, please initiate a behavior management program. There were no behaviors or non-pharmalogical approaches documented. Review of the progress notes, from 1/1/19 through 8/6/19, did not include documentation related to behaviors. There were multiple falls documented. During an observation and interview with the resident on 8/1/19 at 10:59 a.m., the resident was alert, pleasant, and walking in his room using the rolling walker. When asked if he knew what medications he was taking, the resident responded, No, but I can find out. When interviewed on 7/31/19 at 11:12 a.m., the Registered Nurse Manager (RNM) said the resident did not done well when a GDR was attempted. The RNM said she was unable to determine when the last GDR was done for the resident and why it failed. She said behaviors should be documented on the behavior documentation sheet or in the progress notes. The RNM and surveyor reviewed the behavior documentation sheet and medical record and were unable to find any behaviors documented. During an interview on 8/1/19 at 10:09 a.m., the Clinical Pharmacist said the physician should be documenting why a GDR was contraindicated. She said she could not find any documented behaviors. When interviewed on 8/2/19 at 10:01 a.m., the Primary Physician said the resident was on psychoactive medications because he has [MEDICAL CONDITION] and dementia. He said the Nurse Practitioner that follows the resident did not recommend a GDR. The physician said he could not find any information as to when the last GDR was done, or any other reason for the medication other than dementia. He said the resident's behavior was wandering and falling at night. The physician said [MEDICATION NAME] would not be appropriate for wandering or falling and it could contribute to the falls. He said maybe a GDR could be considered. 2. Resident #18 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/3/19, revealed the resident had severely impaired cognition and no behaviors in the look back period. The MDS Assessments, dated 12/12/18 and 1/23/19, revealed no behaviors, [MEDICAL CONDITION], or mental status changes in the look back period. The Comprehensive Care Plan, dated (MONTH) 2019, revealed that the resident received [MEDICAL CONDITION] drugs related to dementia with behavioral disturbances and depression. Interventions included to observe for behaviors, refocus attention to activities, and psychiatric evaluation as needed. If no symptoms ask if the medication can be reduced. The initial physician order, dated 4/17/18, and physician orders from (MONTH) 2019 through (MONTH) 2019, included [MEDICATION NAME] (an antipsychotic medication) twice daily. The order does not include a specific condition or signs and symptoms the resident was experiencing. The psychiatric Registered Nurse (RN) note, dated 1/15/19, revealed the resident was pleasant, polite, and had a bright affect. The resident had decreased sleep at night due to pain and received [MEDICATION NAME] twice daily. The 1/29/19 Psychiatric RN note revealed the resident was readmitted to the facility following amputation of the right leg. She was calm but complained of pain and received [MEDICATION NAME] twice daily. A 3/1/19 psychiatric RN note revealed the resident had increased behavioral concerns and paranoia. She was missing her family and believed she had been at the nursing home for only eight weeks. The Nurse Practitioner note, dated 5/17/19, includes that the resident was complaining of painful sinuses and became weepy. Under psych/behavioral it was documented positive for agitation, depression, hallucinations, sleep disturbance, nervous, anxious, and irritability. Review of the nursing progress notes, from 4/1/19 through 8/2/19, did not include any documentation related to behaviors. The Pharmacy Monthly Medication Regimen Review, dated 5/1/19, questioned a GDR of the [MEDICATION NAME]; however, staff were unable to find any recommendation to the physician. The physician note, dated 7/25/19, revealed that the resident's mood appears anxious and she was stable on [MEDICATION NAME] twice daily. Intermittent observations, from 7/29/19 through 8/2/19 revealed that the resident was calm, sitting in her wheelchair in the common area, and watching TV. When interviewed on 7/29/19 at 10:25 a.m., the resident's family member said when the resident was first admitted to the facility, she was on another unit that was mainly for residents with behaviors. She said at that time the resident had already had one leg amputated and she was having such pain in her other leg that she was out of her mind. The family member said that her pain was terrible. She said after the second leg was amputated, her pain went away, and she was mentally clear on most days now. During an interview on 8/1/19 at 1:38 p.m., the primary day Certified Nursing Assistant (CNA) said the resident's mental state varies. She said some days the resident thinks that she is at work or the children are coming home soon. She said she has never witnessed the resident hallucinating, and she had never been combative. She said the resident does sometimes cuss you out in Spanish. The CNA said most of the resident's behaviors center around going to the bathroom. She said the resident does cry and when she does, she asks her questions about her children or does a little dance for her, and then the resident laughs and stops crying. She said it helps to get the resident out of that mood. Interviews conducted on 8/2/19 included the following: a. At 10:16 a.m., the Physician said the specific condition/signs/symptoms for the prescribing of [MEDICATION NAME] for the resident was dementia. He said the reason the resident was put on the medication was because at that time she had an infection, poor circulation, amputation, some behavior problems, and needed the medication. He said she was on the [MEDICATION NAME] now and doing well. The physician said he did not see any adverse effects from the medication and would consider weaning her off the medication now. b. At 10:56 a.m., RNM #2 said she did not see any other behavioral progress notes for the resident. She said the resident's behaviors include yelling in English and Spanish and are usually centered around the bathroom or her children not visiting. RNM #2 said that she saw where the GDR was mentioned but it was never done. c. At 2:33 p.m., the primary evening CNA said the resident likes to sleep in a lounge chair in the common area because she does not like to be alone and wants to be able to answer the door if someone comes. She said the resident has some yelling behaviors that are centered around going to the bathroom. She said when that happens, she asks the resident to calm down so she can understand her need. (10 NYCRR 415.12(1)(2)(ii))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Moore Place) of five residential dining rooms and for one (Resident #119) of four residents reviewed for positioning and mobility, 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, staff were not using an effective disinfectant product on the surfaces of, including but not limited to, dining tables and counter tops in the resident dining room and staff did not clean and repair the resident's electric wheelchair appropriately. This is evidenced by the following: 1. Observations and interviews on 7/31/19 in the Moore Place dining room, were as follows: a. At 10:30 a.m., Certified Nursing Assistant (CNA) #1 said to clean tables, he uses a sanitizer and pointed to a dispenser, fastened to the wall by the sink, labelled Oasis 146 (product to sanitize hard, non-porous food contact surfaces such as tables, counter and food processing equipment). He said he wets a dishcloth with the product and wipes the tabletops. CNA #1 said he did not know who was responsible to restock the product or check the sanitizing level. He said the tube dispensing the sanitizer was black and dirty. CNA #1 looked at the container of sanitizer concentrate and said it was empty. He said he did not know who was responsible to get a new one or who to contact. b. At 10:49 a.m., CNA #2 said she uses Oasis 146 or the green detergent to clean and sanitize. CNA #2 picked up the detergent and the label read Green Works, 98 percent naturally derived manual pot and pan detergent commercial solution. At about 10:51 a.m., a Registered Nurse Manager (RNM) looked at the tubing coming from the Oasis dispenser and said it was black and there were clumps of debris inside of it. The RNM said she did not know what product should be used to sanitize tabletops but she would text the Director of Food Service (DFS) to find out. c. At 11:04 a.m., CNA #2 said the DFS told the RNM that nursing staff should be using Dispatch (cleaner disinfectant towels with bleach). CNA #2 had a canister in her hands and put it on the counter for use. CNA #2 said that staff use the wipes in resident rooms, but she has never seen it used in the dining room. d. At 11:16 a.m., the Senior Manager/Food Services said that the nursing staff was responsible to clean surfaces in the dining rooms. She said the staff are supposed to use Dispatch wipes for sanitizing. She said that Green Works was not a sanitizer and that the Oasis 146 dispenser should have been removed from service. 2. Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/1/19 Minimum Data Set Assessment included the resident was cognitively intact. During an observation and interview on 8/1/19 at 11:36 a.m., the resident said he could not remember if his chair had ever been cleaned. The electric wheelchair, equipped with a mouth piece to work the joy stick used for mobility, had buildup of dried food on it and dirt and debris on the base. The left armrest had exposed metal. Two yellow sponges were taped to the armrest that the resident said were applied by his friend as a cushion. The resident said he needed to have his chair fixed but he did not want to have it taken away because that is the only way he can get around. In an observation and interview on 8/1/19 at 12:01 p.m., when shown the chair, the RNM said yes, the chair needed cleaning. She said they are cleaned weekly but when she saw the dried built up dirt she said she did not know when it was last cleaned. The RNM stated that covering the armrest with two sponges was not appropriate and that they were trying to get him a new chair. When asked if the armrest was fixable, she said yes. When shown the dirty table strapped to chair and the mouth piece, she said it needed to be cleaned. The RNM said that the resident leaves the unit all day (making it difficult to clean). When asked if his leaving would have any impact on cleaning the chair at night, she said no. She said the resident sustained [REDACTED]. The RNM said she did not have a procedure that is followed for any maintenance of the chair. When interviewed on 8/2/19 at 2:13 p.m., the Occupational Therapist said staff had not let her know the chair required fixing and would have to call Monroe to fix the arm as it would be unsafe. She said she had evaluated the residents for positioning, but evaluation of the chair and its condition had not been done. In an interview on 8/6/19 at 10:06 a.m., the Administrator said that the wheelchair had been added as part of the grooming audit and was cleaned by the Director of Nursing and a staff member (after surveyor intervention) and is now on a routine schedule for cleaning. (10 NYCRR 415.19)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that the for one (Resident #23) of two residents reviewed for tube feedings, the facility did not implement interventions in accordance with the resident's care plan. Specifically, there was no documented evidence that the resident was weighed weekly as per his plan of care and physician orders. This is evidenced by the following: Resident #23 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 11/8/17, included that the resident had moderately impaired cognition and required extensive to total assistance of staff for all activities of daily living. The Comprehensive Care Plan, dated as last reviewed on 1/26/18, included that the resident's nutritional and hydration status was at risk due to taking nothing by mouth and receiving all nutrition and water via a feeding tube, a history of urinary tract infections, kidney stones, a recent ileus (paralysis of the bowel) requiring hospitalization , and currently on treatment for [REDACTED]. Approaches include to monitor weights. Review of the monthly physician orders [REDACTED]. Review of a monthly Nutrition Note, dated 12/26/17, and a quarterly assessment, dated 1/26/18, both signed by the Registered Dietician (RD), revealed that the resident continues weekly weights and was down 3.3 percent over six months, was tolerating tube feedings, and that gradual weight loss was desirable and she will continue to monitor monthly for high risk. Review of intake records from August 2017 through February 2018 revealed weekly weights written at the top and highlighted weekly on Thursdays but actual weights were documented only once in August, September, November, and January, twice in October and three times in December. When interviewed on 2/8/18 at 3:53 p.m., the RD stated that the resident was on weekly weights because he was a high risk due to several hospital admissions and stomach issues. She said that she knew the staff were not doing weekly weights and spoke with the Nurse Manager. The RD said that the Nurse Practitioner said a gradual weight loss was acceptable due to the resident's high Body Mass Index but that it should be gradual and she did expect staff to get weights weekly. When interviewed on 2/9/18 at 11:19 a.m., the Registered Nurse Clinical Coordinator stated that she was not aware staff were not doing the resident's weekly weights. She said if staff are unable to weigh the resident for any reason, she should be notified. (10 NYCRR 415.11(c)(1))

Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 216 and #NY 187) completed on 2/9/18, it was determined that for two of ten residents reviewed for activity of daily living, the facility did not provide the necessary services to maintain good grooming and personal hygiene. Issues involved the lack of nail care (Residents #44 and #166) and lack of hair care (Resident #44). This is evidenced by the following: 1. Resident #44 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/14/17, revealed the resident was severely cognitively impaired and required the extensive assistance of two staff for personal hygiene. Physician orders, dated 2/2/18, included a fingernail assessment every Thursday. Review of the current Interdisciplinary Care Card revealed the resident's shower was scheduled for Thursdays, and the resident was dependent on staff for bathing. Review of the February 2018 Treatment Administration Record (TAR) included an entry for a fingernail assessment every Thursday. The entry was not signed as completed on 2/1/18 and was signed as completed 2/8/18. During an observation on 2/5/18 at 2:20 p.m., the resident's hair was greasy and all ten fingernails had black debris under them. On 2/6/18 at 8:46 a.m. and 3:30 p.m., the resident had brown/tan debris under five fingernails on the right hand, and the five fingernails on the left hand were half filled with brown/black debris. In addition, the resident's hair was greasy. On 2/7/18 at 8:55 a.m., the resident's fingernails on the right hand were clean, the fingernails on the left hand were observed with tan debris under the nails and the resident's hair was greasy. On 2/9/18 at 8:49 a.m., three fingernails on the resident's left hand had black debris under the nails. During an interview on 2/5/18 at 2:24 p.m., the resident's family member stated the resident's fingernails were always like that and that he was told by staff the debris under the fingernails was from the newspaper. When interviewed on 2/7/18 at 12:01 p.m., Certified Nursing Assistant (CNA) #1 stated the resident had greasy hair, however, the family member does not like the resident to get her hair done at the beauty shop. CNA #1 stated they could wash her hair more frequently on the unit. CNA #1 said nail care is done with the resident's shower. CNA #1 said the resident had some jagged nails. During an interview on 2/9/18 at 9:13 a.m., the Licensed Practical Nurse (LPN) stated the resident was showered by the night staff and she would have received a shower on 2/8/18. The LPN stated the night staff would be responsible for ensuring the nails are checked and cleaned. The LPN stated the initials documented on the TAR for fingernail assessment indicated the nails were checked and cleaned. She said it would be the CNAs' responsibility to ensure the resident's fingernails were cleaned in between showers. 2. Resident #166 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/11/18, revealed that the resident had severely impaired cognition and required the extensive assistance of one staff for personal hygiene. The current Interdisciplinary Care Card revealed that the resident required one staff for assistance with all activities of daily living. During observations on 2/5/18 at 10:40 a.m., and 2/6/18 at 9:26 a.m., the resident had dark debris underneath all ten fingernails. On 2/7/18 at 12:46 p.m., the resident was observed in the unit dining room with his lunch tray and his fingernails still had dark debris underneath them. On 2/8/18 at 11:09 a.m., the resident was sitting in the common area and all of his fingernails had dark debris underneath them. During an observation and interview on 2/8/18 at 11:11 a.m., the Registered Nurse Manager (RNM) was asked by the surveyor to observe the resident's fingernails. The RNM approached the resident and looked at his fingernails. The RNM then walked with the resident towards his room. At 11:25 a.m., the RNM stated that she had cleaned the resident's fingernails herself. The RNM said that the resident's shower was that morning and he should have had his fingernails cleaned then. The RNM said that the CNA should be caring for the resident's fingernails as needed and not just on shower days. When interviewed on 2/8/18 at 11:33 a.m., CNA #2 said that she was assigned to the resident and gave him a shower and shaved him that morning. CNA #2 stated that she did not provide nail care for the resident due to being short on time. (10 NYCRR 415.12(a)(3))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two of five residents reviewed for pressure ulcers, the facility did not provide the necessary care and services to promote the healing of existing pressure ulcers and prevent the development of additional pressure ulcers. The issues involved the lack of skin assessments (Resident #154), the lack of timely repositioning, and the lack of appropriate pressure relieving devices (Residents #154 and #110). This is evidenced by the following: The facility policy and procedure, Skin Inspection and Care, last revised December 2016, directed the Clinical Leader/Nurse Manager will be responsible for monitoring response to treatment/interventions and adjust plan of care if necessary. Pressure ulcers and wounds should show signs of stabilization or healing within two to four weeks. The treatment plan should be re-addressed if no signs of stabilization or healing within two to four weeks, or sooner if deterioration occurs. Treatment strategies included the following: protect the area from pressure using one or more techniques/devices and repositioning was essential. Turn and re-position approximately every two hours when in bed and keep all pressure off the affected area as much as possible using pillows/wedges for positioning. Use appropriate cushion in chair, reposition, shifting points under pressure approximately every one to two hours. Do not leave the resident in a chair for prolonged periods of time. If the resident is able, have them shift weight approximately every 15 minutes when up in a chair. 1. Resident #154 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/26/17, revealed that the resident's cognitive skills for daily decision making were moderately impaired, required extensive assistance of two or more staff for bed mobility, transfers and toileting. Additionally, the resident was always incontinent of bladder, was at risk for pressure ulcers, and had three Stage II (partial thickness skin loss) pressure ulcers at the time of the assessment. A Braden Scale for Pressure Ulcer Risk, dated 10/24/17, revealed that the resident scored a 17 and was at mild risk for pressure ulcers. There was no documentation that the resident's pressure ulcer risk was re-evaluated when readmitted from the hospital on [DATE] or 1/18/18. The Comprehensive Care Plan (CCP), dated 12/29/17, revealed that the resident was at risk for pressure ulcers related to incontinence of bowel and bladder, the use of briefs, non-ambulatory with the use of a wheelchair for mobility, and the use of a mechanical lift for transfers. The goal was for the resident to be free from pressure ulcers or skin breakdown. Approaches included skin checks and Braden Scale per protocol and transfers, incontinence care, and position per Interdisciplinary Care Card. The CCP had not been updated to reflect the presence of actual pressure ulcers on her re-admission to the facility on [DATE] or again on 1/18/18. The current Interdisciplinary Care Card directs to turn and position the resident every two to three hours and as needed with the assistance of two staff for bed mobility, to toilet every two to three hours and as needed, and to apply [MEDICATION NAME] Cream to the buttocks every shift. A medicine Discharge Summary/Hand-off Summary, dated 12/19/17, revealed that the resident had a sacral decubitus, needed a specialty mattress, frequent turning, and cover wound areas with Allevyn (an absorbent foam wound dressing). A Progress Note, dated 12/19/17, documented that the resident had three Stage II pressure ulcers to her buttocks that were cleansed with saline and Allevyn applied per physician order. Physician admission orders [REDACTED]. Review of the Progress Notes and Wound/Skin Progress Notes, from 12/20/17 to 1/17/18, did not reveal that on-going documented assessments of the pressure ulcers had been done. Wound/Skin Progress Notes, dated 12/26/17, documented that on the weekly skin check there were no areas of concern observed or reported. On 1/1/18, it was documented that there were no new skin issues. On 1/15/18, it was documented that no new skin conditions were observed. On 1/18/18, a re-admission skin assessment documented a Stage II open area to the coccyx. On 2/1/18, it was documented that the resident had two unstageable pressure areas, one to the coccyx and one to the left buttock. When observed on 2/8/18, the resident was sitting in a geri-chair without a pressure relieving cushion or being repositioned from 8:10 a.m. until she was put back into bed on a standard mattress at 1:28 p.m. Incontinence and wound care was done at that time. After incontinence care was completed the staff turned the resident onto her left hip. The resident had an oval shaped, unstageable ulcer to the left buttock consisting of approximately 80 percent slough (a mass of dead tissue) in the center and the remainder of wound was approximately 20 percent pink granulation tissue (new, healing surface of a wound). During an observation on 2/9/18 from 7:50 a.m. to 12:35 p.m., the resident was sitting in a geri-chair without a pressure relieving cushion in the chair and the resident was not repositioned. In an interview on 2/9/18 at 12:18 p.m., Clinical Leader #1 stated that if a pressure ulcer was identified on admission, the Registered Nurse (RN) should assess the wound, notify the provider and obtain treatment orders. Clinical Leader #1 said that she assessed the wound at least once a week with measurements and tissue appearance. After reviewing the Wound/Skin Progress Notes documented after 12/19/17, Clinical Leader #1 stated that there should have been on-going documentation with measurements so one could tell if the wound was improving or getting worse, and looking at the notes she could not tell if the wounds healed or not. Clinical Leader #1 reviewed the Braden Scale for Pressure Ulcer Risk and stated that it was last completed in October 2017. She said that it should be done at least quarterly, when there is a change, or if a resident develops a pressure ulcer. Clinical Leader #1 stated that if a resident has an unstageable pressure ulcer the resident should have a low air loss mattress, a gel cushion for the chair, dietary intervention, and should be turned and positioned frequently. 2. Resident #110 was admitted to the facility on [DATE] and readmitted following a hospitalization on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/1/17, revealed the resident's cognitive skills for daily decision making were severely impaired, ambulated with the limited assistance of two staff, and required the extensive assistance of two staff for transfers and toilet use. The resident was frequently incontinent of urine, was at risk of developing pressure ulcers, had an unhealed Stage II pressure ulcer which was present on re-admission to the facility, and an unstageable deep tissue injury. The CCP, dated 12/4/17, revealed that the resident had cognitive impairments which placed her at risk for skin breakdown. There was an undated handwritten note that documented the resident had Stage III pressure ulcers on the coccyx and ischial. Approaches include to complete a Braden Scale per policy and as needed, provide treatment with dressings, medicated ointments, consult wound care specialist as needed, and culture wound per physician orders. On 2/5/18, a handwritten approach was added to include a chair cushion. The current Interdisciplinary Care Card included to toilet every two to three hours. The Braden Scale for Pressure Ulcer Risk, dated 11/10/17, revealed the resident scored a 21 and was at low risk for pressure ulcers. There was no documentation that the resident's pressure ulcer risk was re-evaluated when readmitted from the hospital on [DATE]. Wound/Skin Progress Notes revealed the following: a. On 11/24/17, a skin assessment upon return from the hospital revealed that the resident had a red area on the right buttock measuring 3 centimeters (cm) x 1.5 cm with the top layer of skin torn off. The type of skin injury and/or stage was not documented. b. On 11/30/17, an unstageable area was noted to the left buttock measuring 1 cm x 4 cm and was dark purple. The type of skin injury was not documented. The open area on the right buttock measured 4 cm x 3 cm. c. On 12/2/17, the inner aspect of the right buttock was a Stage II pressure ulcer with a small amount of serosanguinous (blood tinged) drainage. Additionally, the documentation revealed that the resident preferred to sleep in the lounge chair in the common area and slides or scoots to the edge of the chair. There was no documentation regarding the area on the left buttock. d. On 12/8/17, the inner aspect of the right buttock was a superficial Stage III wound base, covered with slough with a moderate amount of yellow-green drainage. The peri wound measured 4.4 cm x 4.3 cm. The inner aspect of the left buttock was a superficial Stage II which measured 0.4 cm x 0.6 cm. e. On 12/13/17, the Stage III wound on the right buttock measured 4.6 cm x 3.5 cm, was covered in 100 percent slough and there was a moderate amount of dark yellow drainage. The Stage II on the left buttock measured 2 cm x 2.2 cm with the wound bed 100 percent beefy red. In addition, the resident had an open area on the coccyx, a slit measuring 3.5 cm in length. A Mobile Surgical Services Consult Note on 12/20/17, revealed that the resident was evaluated for bilateral buttock pressure ulcers (right buttock Stage II and left buttock Stage III). The resident has had a significant mental decline in the past month. The resident's risk factors for skin breakdown include, but are not limited to, impaired mobility with exposure to friction and shear due to mental decline, incontinence and pain impairing mobility and mood. At the time of the visit, the resident was bent over to the right in a fetal position in the chair moaning. Nursing noted that was now the resident's baseline over the past few weeks. The locations and stages of wounds included the following: unstageable on right buttocks with 100 percent slough with moderate serous discharge; unstageable on left medial buttocks with 100 percent slough with moderate serous discharge, Stage II on the right ischium with shallow partial thickness, and a non-blanchable Stage I on the left ischium. Recommendations included, but was not limited to, a Physical Therapy evaluation for a specialty off-loading cushion. During multiple intermittent observations from 2/5/18 through 2/7/18, the resident was seated in a recliner chair in the common area without a pressure relieving cushion in place. During an observation on 2/7/18 from 9:26 a.m. to 9:50 a.m., the resident was seated in a wheelchair in the common area without a pressure relief cushion. At 9:50 a.m., the resident was transferred to a recliner with a two person assist and a gait belt. There was no pressure relief cushion in the recliner. At 11:31 a.m., the resident was leaning forward in the recliner. At 11:53 a.m., the resident was lifting her buttocks off of the chair and grimacing. At 11:57 a.m., the resident was yelling out and moaning loudly, and was approached by the Registered Nurse Manager (RNM) who elevated the resident's feet. At 12:00 p.m., the resident was transferred to her wheelchair with a two person assist and a gait belt, and taken to her room. There was no pressure relief cushion in the recliner. During the continued observation from 9:50 a.m. until 12:00 p.m., the resident was not repositioned or assisted in off-loading pressure from her buttocks. During a wound observation on 2/8/18 at 10:00 a.m. with the primary Nurse, a Stage II was observed on the left buttock and a Stage III on the right buttock which had a moderate amount of drainage. When interviewed on 2/8/18 at 1:11 p.m., the RNM stated that when the resident first developed the pressure areas it was difficult to implement prevention/treatment interventions due to the resident not remaining in her bed or chair for any length of time. She said the resident would refuse to sleep in her bed and would rest for short periods of time whenever she sat. The RNM said that the resident has a pressure relieving cushion in place but does not have a special mattress. When asked why there was a delay in obtaining the cushion, the RNM stated the cushion was ordered on [DATE] but there was not a cushion in-house. She said that on 2/7/18, another unit was called and they had a cushion that was not in use for the resident. When asked if there was a turning and re-positioning schedule for the resident, the RNM stated that there was not a specific time frame. She said that the resident's toileting schedule was every two to three hours and that was used for repositioning. On 2/9/18 at 11:29 a.m., the RNM stated that the resident currently sleeps in the recliner in the common area as she was able to communicate to staff that she was afraid to be in her room. After reviewing the facility policy for skin inspection and care, the RNM stated that the resident has recently had a decline and has been ill, she is sleeping more and requiring more pain medication and should have had pressure relieving devices and frequent repositioning per the policy. When interviewed on 2/9/18 at 11:48 a.m., the Director of Nursing (DON) stated that upon the resident's return from the hospital, she would have expected that staff ensure the resident's position was changed and she was not sitting for a long period of time. The DON said when the areas were getting worse, the resident's care plan should have been re-evaluated, and changes made to the care plan per facility policy. The DON said she was not aware of the process for ordering chair cushions. (10 NYCRR 415.12(c)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #32) of six residents reviewed for positioning and mobility, the facility did not ensure that each resident received appropriate treatment and services to maintain or improve range of motion. Specifically, splints were not used per the plan of care. This is evidenced by the following: Resident #32 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/7/17, revealed the resident had moderately impaired cognition, required the extensive assistance of two staff for dressing, and had functional limitation in range of motion of one upper extremity. The Comprehensive Care Plan, dated 10/20/17, revealed the resident had a contracture of the right arm and hand. The approaches included positioning and splint per Physical Therapy, Occupational Therapy, and the Interdisciplinary Care Card. The Occupational Therapy Discharge Summary, dated 11/27/17, revealed that staff were educated about splinting techniques and the resident's splinting schedule. The current Interdisciplinary Care Card directed to apply a carrot splint to the resident's right hand every day from 10:00 a.m. to 2:00 p.m. and 6:00 p.m. to 10:00 p.m. per the resident's tolerance. During an observation on 2/5/18 at 1:08 p.m., the resident's right hand was on a pillow and there was no splint in place. The resident's splinting schedule was hanging on the wall above the resident's bed and instructed that the splint was to be applied from 10:00 a.m. to 2:00 p.m. and 6:00 p.m. to 10:00 p.m. everyday as tolerated. When observed on 2/6/18 at 10:00 a.m., the resident did not have a splint applied to his right hand. During an observation on 2/7/18 at 9:04 a.m., the resident was observed sitting in her chair with Geri sleeves applied to both arms and no splint was applied to the right hand. A blue carrot splint was on the resident's dresser. At that time, the Certified Nursing Assistant (CNA) stated the nurse or therapy kept track of the application of the resident's splints. During intermittent observations throughout the remainder of the day, the resident was not wearing his splint. When interviewed on 2/7/18 at 1:54 p.m., Licensed Practical Nurse (LPN) #2 stated the CNA was responsible for applying the splint when cares were completed. LPN #2 stated the nurses were responsible for overseeing the CNAs and the splint schedule, however she did not know if the CNA had applied the resident's splint per the schedule. When interviewed on 2/8/18 at 12:51 p.m., the Occupational Therapist (OT) stated the resident had a contracture of his right hand and used a carrot splint. She stated the CNAs would apply the splint when the resident gets out of bed. The OT stated there are pictures of how to apply the splint and a splint schedule in the resident's room. The OT stated that if the resident was not wearing the splint she would want to be notified. During an interview on 2/9/18 at 8:25 a.m., the Nurse Manager (NM), stated the CNAs were responsible for applying the resident's splint. The NM said the nurses should be checking to ensure the splint was applied. She stated if the resident could not tolerate the splint it should be reported to the nurse and documented in the progress notes. (10 NYCRR 415.12(e)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #162) of three residents reviewed for respiratory care, the facility did not ensure that each resident received the proper respiratory treatment and care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the resident was being administered oxygen at a liter flow greater than the current physician's orders [REDACTED]. Resident #162 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/29/18, revealed that the resident had severely impaired cognition and required oxygen therapy. The facility policy, Oxygen Therapy, last reviewed November 2010, directed to validate the presence of any oxygen order, flow rate and delivery mode. Physician orders, dated 2/2/18, included oxygen at two liters per minute via nasal cannula continuously. The February 2018 Treatment Administration Record (TAR) included an entry for that oxygen order and was initialed as administered every shift from 2/1/18 through the night shift 2/8/18. The current Comprehensive Care Plan (CCP) does not include oxygen use. A review of the medical record revealed Nursing Progress Notes on 2/2/18, 2/3/18, 2/4/18, and 2/7/18 documented that the resident had been placed on oxygen at 3 liters per minute. Observation and interviews conducted on 2/8/18 included the following: a. At 11:40 a.m., the resident was seated in the common area with oxygen being administered at three liters per minute via nasal cannula and oxygen concentrator. b. At 11:54 a.m., the assigned Licensed Practical Nurse (LPN) stated that the resident had a physician order [REDACTED]. The LPN said that she had been placing the resident's oxygen at 3 liters since that time. The LPN said she was unable to find a physician order [REDACTED]. c. At 11:57 a.m., the Registered Nurse Manager (RNM) stated that the LPN adjusts or maintains the oxygen liter flow on the resident's oxygen concentrator. She said that the Certified Nursing Assistants are allowed to place the oxygen nasal cannula on the resident but are not allowed to adjust the oxygen liter flow. When asked if the resident had a CCP for oxygen, the RNM reviewed the medical record and said there was no CCP in place for oxygen use. She said there should be a CCP for oxygen usage. The RNM said that the resident's current physician orders [REDACTED]. (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 #165) of one resident reviewed for [MEDICAL TREATMENT], the facility did not ensure that each resident received services consistent with professional standards of practice. Specifically, there was no documentation that the facility was following recommendations from the resident's [MEDICAL TREATMENT] center for fluid restrictions. This is evidenced by the following: Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/3/18, revealed that the resident was cognitively intact and required staff supervision and set-up assistance for eating. Review of the current facility policy, [MEDICAL TREATMENT] Guidelines, directs staff to flag the resident's chart with any returning documentation from the [MEDICAL TREATMENT] provider for medical staff to review. During observations and interviews on 2/8/18 at 8:47 a.m. and 10:22 a.m., the resident was in his room, and on his bedside stand were several large styrofoam cups of soda approximately half full. When asked if he was on a fluid restriction, the resident responded not that he was aware of. When asked if anyone asked him how much of the soda he drinks he responded no. The resident said staff bring him several cups of soda a day. Review of the medical record revealed the following: a. In physician progress notes [REDACTED]. b. An Initial Nutrition Assessment, dated 1/2/18, documented that the resident reported that he usually ate more at home and was not on a diet. The physician discontinued the resident's fluid restriction on 12/29/17. c. A Comprehensive Care Plan, dated 1/8/18, revealed the resident was at risk for weight fluctuations related to [MEDICAL CONDITION] and [MEDICAL TREATMENT], and approaches included to monitor weights and diet per physician and [MEDICAL TREATMENT] dietician. d. A Nursing Home Communication Form from the resident's [MEDICAL TREATMENT] center to facility staff, dated 1/16/18, has a starred (*) notation to Maintain Fluid Restrictions. e. In a Nutrition Progress Note, dated 1/24/18, the Registered Dietician (RD) documented that the resident's average fluid weight gain between treatments was above his goal but that he was no longer on a fluid restriction and was non-compliant at home with his diet. f. Physician orders, dated February 2018, included a renal diet. There was no documentation in the medical record that the communication from the [MEDICAL TREATMENT] center regarding the resident's fluid restriction on 1/16/18 was relayed to dietary or medical. Review of Intake and Output Flowsheets, dated 1/19/18 through 2/7/18, revealed intakes recorded every shift in cubic centimeters (cc). Thirteen of the shifts recorded the amount of intake for liquids and intravenous fluids with a 'plus' sign (example: 480 cc's+). Interviews conducted on 2/8/18 included the following: a. At 9:27 a.m. and again on 2/9/18 at 8:48 a.m., the Registered Nurse Clinical Coordinator (RNCC) stated that the resident was on daily intake monitoring but she did not know about a fluid restriction. She said [MEDICAL TREATMENT] Communication Sheets should be reviewed by the nurse accepting the resident from [MEDICAL TREATMENT]. The RNCC said that medical or dietary should have been notified about the notation related to fluid restriction. The RNCC said that a unit assistant delivers the drinks to the residents and that nursing should be monitoring the amounts closer and not using a plus sign when they document fluid intakes. b. At 3:48 p.m., the RD stated that she spoke with the [MEDICAL TREATMENT] dietician on 1/5/18 and reported the resident was not on a fluid restriction. When asked if she discussed fluid restriction after the communication from [MEDICAL TREATMENT] on 1/16/18, the RD said no she did not. The RD said that if a communication was sent related to fluid restriction she should have been notified. (10 NYCRR 415.12)

Based on observation, interviews and record reviews conducted during the Recertification survey, it was determined that for one of three residents reviewed for incontinence care and one of three residents reviewed for respiratory care, 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, staff did not maintain proper infection control practices during incontinence care (Resident #80) and did not clean or replace a soiled oxygen mask in a timely manner (Resident #145). This is evidenced by the following: 1. Resident #80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 12/4/17, revealed that the resident had severely impaired cognition, required extensive assist of staff for toileting and personal hygiene, and was always incontinent of bladder and bowels. During observation and interview on 2/7/18 at 11:25 a.m., the Certified Nursing Assistant (CNA), wearing gloves, cleansed the resident of large amounts of loose stool and with the same gloves applied skin cream to the resident's entire buttocks and peri area. Without removing the soiled gloves, the CNA touched the resident's hands, clothing, mechanical lift equipment, bed controls, supplies, and bathroom and closet door handles and faucets. When interviewed at that time, the CNA stated she should have removed her gloves following incontinence care and before touching all those areas. In an interview on 2/9/18 at 11:03 a.m., the Registered Nurse/Quality and Infection Prevention stated that she expects staff to change their gloves several times during incontinence care and before touching anything clean. 2 Resident #145 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A MDS Assessment, dated 12/29/17, revealed that the resident was cognitively intact and required extensive assistance of staff for personal hygiene. The facility policy, Schedule of Equipment Change Respiratory Services, dated effective June 2017, directs that small volume nebulizer equipment is changed weekly. Physician orders, dated 1/30/18, included [MEDICATION NAME] Nebulizer treatments every four hours as need for wheezing and/or shortness of breath. Review of the Treatment Administration Records for the past two months revealed nebulizer treatments signed off as administered several times a month. During observations and interviews on 2/5/18 at 10:34 a.m., 2/6/18 at 4:05 p.m., and on 2/9/18 at 9:20 a.m., the resident had a nebulizer machine in her room with an oxygen face mask attached with a date of 8/24/17 written on it in black magic marker. The mask was dirty and sticky. The resident stated that she uses the mask regularly, about once a week for wheezing. The resident said she last used the mask last week. When interviewed on 2/9/18 at 9:29 a.m., the RN Clinical Coordinator stated that all oxygen masks should be changed weekly. (10 NYCRR 415.19(b)(2)(4))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 542) completed on 11/1/17, it was determined that for one (Resident #1) of three residents reviewed for Incident Reports, the facility did not provide the necessary care and services to attain or maintain the highest physical wellbeing in accordance with the comprehensive assessment and plan of care. Specifically, the resident was removed from the floor without a Registered Nurse (RN) assessment, a lack of a timely RN assessment following the resident's complaints of pain, and the lack of timely physician notification. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/10/17, revealed the resident had severely impaired cognition and wandering behavior. The undated Interdisciplinary Care Card identified by the Administrator as effective on 5/9/17, revealed that the resident had a behavior of independently placing himself on the floor and may require assistance to rise. The undated facility Investigation Summary revealed that on the night of 5/9/17 through 5/10/17, the resident was noted to have increased pain in his lower extremities. The resident was found seated on the floor in another resident's room on 5/9/17 between 6:00 p.m. and 7:00 p.m. and was assisted to his feet by two Certified Nursing Assistants (CNAs). The CNAs transferred the resident to a shower chair and then to his bed. At that time, the resident gestured to his back side and said that his left hip hurt. The CNAs reported that the resident had bruises on his hips and both CNAs separately reported the resident's complaints of pain and the hip bruises to RN #3. RN #3 said that the CNA reports of bruising did not impress her as a new complaint due to a previously documented bruise. RN #3 performed an assessment at 2:30 a.m. but could not determine if the pain was localized to one extremity or just overall joint pain. The X-ray Report, dated 5/10/17, revealed a fracture to the resident's right hip. Interviews conducted on 10/24/17 included the following: a. At 10:55 a.m., the Administrator stated that on 5/9/17, during the evening shift, the resident was found on the floor and that it was not considered a fall. The Administrator said that some of the residents on the neuro-behavior unit spend a lot of time on the floor. The Administrator said there were no specific guidelines directing when a CNA could assist the resident off the floor. b. At 11:00 a.m., the Director of Nursing (DON) stated that prior to the 5/9/17 incident, the procedure for the CNAs to remove a resident from the floor was not clear. The DON said since that incident the CNAs are permitted to get the residents off the floor if the resident was witnessed putting themselves on the floor and was care planned for placing themselves on the floor. c. At 11:10 a.m., RN #1 stated that when she received report on 5/10/17 at 6:00 a.m. she was alerted that overnight the resident was having bilateral hip pain and decreased Range of Motion. RN #1 instructed staff to keep the resident in bed and non-weightbearing. RN #1 stated that at 7:00 a.m., the resident's CNA reported that the resident demonstrated pain when she provided morning care, and the physician ordered an x-ray during morning rounds. RN #1 said that if a resident complains of pain after being found on the floor, then staff should investigate, assess, and follow up with the physician. She said if a resident was observed putting themselves on the floor, the staff are able to assist the resident up. RN#1 said if the resident is found on the floor, the resident should not be moved and the nurse should be notified. d. At 11:30 a.m., CNA #1 stated that on 5/9/17 between 6:00 p.m. and 7:00 p.m., she was in the common area. She said she did not know where the resident was at that time. She said the resident should have been in an area where she could see him. CNA #1 stated that CNA #5 went to look for the resident and found him on the floor. CNA #1 stated that CNA #3 went to RN #3 and said that the resident had a big bruise on his butt. RN #3 said the resident had the bruise and an Incident and Accident Report had already been done. CNA #1 stated that CNA #5 then went to RN #3 with the resident in a shower chair, said the resident was sitting on the floor and was acting like he was in pain, and it was hard for him to stand. CNA #1 stated that she does not recall RN #3's response. CNA #1 stated the RN must assess residents found on the floor. e. At 12:30 p.m., CNA #3 stated that on 5/9/17 CNA #5 called him for help in getting the resident off the floor. CNA #3 stated that the resident could stand but when he started to ambulate, the resident groaned like he was in pain and required a lot of support. CNA #3 said that he did not feel comfortable with ambulating the resident so they ambulated him to the shower chair. f. At 12:45 p.m., CNA #4 stated that on 5/9/17, prior to when the resident was found on the floor, he was ambulating fairly well with one assist. CNA #4 stated that during toileting rounds, which occurred after the resident was removed from the floor, she tried to get him out of bed with another CNA, but the resident was adamant that he was in pain and she told RN #3. g. At 2:30 p.m., RN #2 stated that if she had been told that the resident was found on the floor, that would have prompted her to assess the resident. RN #2 stated that she did not direct RN #3 not to call the on-call physician. h. At 2:45 p.m., RN #3 stated that CNA #5 reported to her at 9:30 p.m. that the resident's leg hurt and she planned to assess the resident but forgot. At 2:30 a.m., the night CNA called her into the resident's room and RN #3 assessed the resident's bilateral lower extremity pain. RN #3 stated she notified RN #2 of her findings, and RN #2 said they did not need to disturb the on-call physician. When interviewed on 10/25/17 at 11:00 a.m., the physician stated that he should be notified for any changes in condition. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 018) completed on 5/17/17, it was determined that for one (Resident #1) of three residents reviewed for abuse, neglect, or mistreatment, the facility staff did not immediately report mistreatment to administration. This is evidenced by the following: Resident #1 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/28/17, revealed the resident's cognitive skills for daily decision making are severely impaired. The undated Facility Investigation Summary revealed that on 4/5/17 at 7:30 p.m. the resident was behind the nurses' station with both doors secured and locked. The resident was described as yelling and asking peers to help her get out. Certified Nursing Assistant (CNA) #1 discovered the resident behind the nurses' station and assisted her out. The incident was reported to the State agency on 4/12/17 by the Director of Nursing (DON). Interviews conducted on 5/9/17 included the following: a. At 2:15 p.m., CNA #2 stated that on 4/5/17 on the evening shift she saw the resident behind the nurses' station crying. She said CNA #1 brought the resident to her and reported that the resident said that Licensed Practical Nurse (LPN) #2 locked her behind the desk. CNA #2 stated that the resident could not get out either door at the nurses' station. CNA #2 said that this occurred around 7:15 p.m., and she reported it to the Registered Nurse (RN) Supervisor between 7:45 p.m. and 8:00 p.m. b. At 2:35 p.m., the RN Manager (RNM) stated that on 4/6/17 during the day shift she found a handwritten statement under her office door written by CNA #2. The RNM said that CNA #2's statement documented that on 4/5/17, during the evening shift, LPN #2 put the resident behind the nurses' station, shut the doors, and the resident could not get out from behind the nurses' station. The RNM stated that she did not interpret the statement as abuse, neglect, or mistreatment and did not discuss the incident with the DON until a week later. The RNM said that she understands that she overlooked something very serious. c. At 3:20 p.m., CNA #1 stated that on 4/6/17 between 6:30 p.m. and 7:00 p.m., she came out of another resident's room and saw Resident #1 behind the nurses' station with the doors closed and locked. CNA #1 said that the resident was crying and saying she wanted to get out, so she let the resident out. CNA #1 stated that she reported the incident to LPN #1. She said the RN Supervisor came to the unit at approximately 9:00 p.m. and she again reported the incident. Interviews conducted on 5/17/17 included the following: a. At 2:00 p.m., the RN Supervisor stated that on 4/5/17 she recalled speaking to the CNAs around 9:30 p.m. regarding LPN #2 placing the resident behind the nurses' desk with the two doors locked. The RN Supervisor said that the resident would not be able to unlatch the door because it is not a simple latch. The RN Supervisor stated that she asked CNA #2 for a statement and gave it to the RNM the following morning. b. At 2:20 p.m., LPN #1 stated that on 4/5/17 around 5:30 p.m. to 6:00 p.m., she observed LPN #2 take the resident in her wheelchair to the nurses' station. She said at that time, LPN #2 said she was putting the resident behind the nurses' station, shutting the door, and going on break. LPN #1 stated that she could hear the resident yelling to let her out. LPN #1 said that she does not know why she did not report the incident. c. At 3:00 p.m., the DON stated that the incident should have been reported to her immediately. d. At 3:10 p.m., the Administrator stated that when staff observe something inappropriate they are expected to report it to the DON or Administrator immediately. The facility policy, Abuse/Neglect Prohibition, reviewed October 2016, included involuntary seclusion as a form of mistreatment. The policy indicated that it is the legal obligation of anyone who witnesses an incident, verbal statement or report, or has reason to believe an incident of abuse, neglect, or mistreatment has occurred to report it immediately to their supervisor, administration, or Administrator on call, and the NYS Department of Health Hotline. (10 NYCRR 415.4(b)(2))

Based on interviews and record reviews conducted during a Recertification Survey and complaint investigation (#NY 560) completed on 11/8/16, it was determined that for 3 of 32 residents reviewed for professional standards, the facility did not provide services consistent with professional standards of quality. The issues included a physician order that was not transcribed correctly onto the Medication Administration Record [REDACTED]. This is evidenced by the following: 1. Resident #262 was admitted on [DATE] with [DIAGNOSES REDACTED]. The physician order, dated 7/2/16 at 5:00 p.m., included [MEDICATION NAME] 2.5 milligram (mg)/ 3 milliliter (ml) nebulizer solution, use one vial in nebulizer every two hours. The July 2016 MAR indicated [REDACTED]. The entry included the initials of two staff members indicating they had both checked the physician order against the MAR for accuracy. A second entry on the MAR indicated [REDACTED] During an interview on 11/4/16 at 9:58 a.m., the Nurse Manager (NM) stated the physician order for [REDACTED]. She said the night nurse should be checking all orders too, so sometimes a third check is completed. The NM reviewed the physician order and stated there were three checks of the [MEDICATION NAME] order and a transcription/medication error occurred. 2. Resident #76 was admitted on [DATE] with [DIAGNOSES REDACTED]. The current physician orders, dated 10/5/16, included to change the Foley catheter every four weeks. The order did not include the size of the Foley catheter. A nursing progress note, dated 7/14/16, revealed an 18 French Foley catheter with a 10 cubic centimeter (cc) balloon was placed. A review of the physician/urology notes from August 2016 to October 2016 does not include the Foley catheter size. Review of the August 2016 MAR indicated [REDACTED]. A nursing progress note, dated 10/3/16, documented the Foley catheter was falling out and was replaced with an 18 French Foley catheter per physician order. Review of the October 2016 MAR indicated [REDACTED]. When interviewed on 11/4/16 at 1:14 p.m., Licensed Practical Nurse (LPN) #1 stated she had assisted with the Foley catheter change on October 4th. She stated the urology note usually documents the catheter size. LPN #1 stated the physician order should include the size of the catheter. She said if the size was not included in the physician's orders she would follow the size documented in the urology note. LPN #1 reviewed the record and computer urology notes and stated the Foley catheter size was not documented. At that time, LPN #2 stated the Foley catheter size should be included in the physician order. The NM was unavailable for interview. Review of the facility policy Indwelling Catheter, dated 1/26/11, revealed that all catheter orders including admission and readmission will include size and medical justification for use and continued use as necessary. 3. Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound/Skin Progress Notes included the following: a. On 7/20/16, a LPN documented that the resident had an open area on the right buttocks which was red and purplish in color. Skin prep (protective barrier) and A&D (skin protective ointment) was applied. b. On 7/21/16, the same LPN documented the right buttocks wound was opened, red and purple in color, and measured 3.5 centimeters (cm) by 1 cm. Skin Prep with a dry sterile dressing was applied. A Registered Nurse (RN) progress note, dated 7/24/16, revealed that staff reported an abrasion to the right buttocks. The RN described the area as red and purple in color with some skin removed. A physician communication form, dated 7/26/16, documented that the open area on the right buttocks measured 3.5 cm by 1 cm, and was red and purple in color. Review of the RN Wound/Skin progress notes included the following: a. On 7/30/16, it was documented that the resident had an abrasion to the right buttocks measuring 4.5 cm by 2.5 cm and an Allevyn (a specialized dressing) was applied. b. On 8/4/16, it was documented that the resident continues to have a dark area to the right buttocks measuring 4.6 cm by 2.8 cm. The note indicated the Skin Prep was applied and the area was covered with Allevyn. c. On 8/12/16, it was documented the area to the right buttocks was closed and Skin Prep was applied. A review of the physician orders, dated 7/13/16 through 8/19/16, revealed no orders for skin treatments to the open area on the right buttocks. Interviews conducted on 11/7/16 included the following: a. At 11:21 a.m., LPN #1 stated there should be physician orders for treatments. b. At 11:45 a.m., the RN/NM stated the resident does not have physician orders for treatment. She said there should be physician orders for all treatments. (10 NYCRR 415.11(c)(3)(i))

Based on observations, interviews, and record reviews, it was determined that for one (Resident #12) of one resident reviewed for quality of care related to pain management, the facility did not provide the necessary care and services to attain and maintain the resident's highest practicable well-being. Specifically, the resident had daily documented complaints of severe pain and the medical team was not notified in a timely manner for a re-assessment of pain control. This is evidenced by the following: Resident #12 has [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 9/27/16, documented that the resident is cognitively intact and reported a pain level of 8 out of 10 (with zero being no pain and 10 as the worst pain you can imagine) frequently. Additionally, it is documented that the resident's pain was moderate that made it hard for her to sleep at night and has limited her day to day activities. The current nursing Comprehensive Care Plan revealed that the resident has pain. Approaches included: to assess for signs of discomfort, document and report changes to medical, medicate for pain and assess for effectiveness and side effects. In an observation of wound care for a decubitus ulcer of the buttocks on 11/3/16 at 9:45 a.m., the resident was moaning and jerking during the wound care which required packing. When interviewed at that time, the resident stated her pain level was a 10. She said she had some pain medication earlier but that it was not working. Review of the medical record included the following: a. Current physician orders [REDACTED]. On 10/20/16, the physician added [MEDICATION NAME] (pain reliever consisting of a combination of [MEDICATION NAME] (a narcotic at 5 mg and Tylenol at 325 mg), one tablet every eight hours as needed for pain. b. A physician progress notes [REDACTED]. c. MARs for October 2016 revealed the as needed Tylenol was administered daily on 19/26 opportunities rating the resident's pain consistently 8-10 on a pain scale of 1-10. The as needed [MEDICATION NAME] was administered twice daily from 10/20/16 through 11/2/16, and the resident was consistently rating her pain level a 10 from 10/27/16 through 11/2/16. The resident's pain level was not documented from 10/20/16 to10/27/16. d. A surgical consult, dated 11/2/16, included that the resident has a full thickness decubitus ulcer with tunneling of approximately 4 centimeters through the gluteal muscles. In an interview on 11/4/16 at 11:12 a.m., the Registered Nurse (RN) stated that the resident is in more pain. She said she knows that it hurts the resident when they do the dressing changes. The RN said that the resident weighs almost 300 lbs. and one [MEDICATION NAME] may not be enough as the wound has advanced. She said the Nurse Practitioner was not aware of the increased pain but she would inform her. Review of the physician orders, dated 11/4/16, (after surveyor intervention) included to increase [MEDICATION NAME] to one or two tablets every four hours as needed. When interviewed on 11/8/16 at 10:41 a.m., the RN/Nurse Manager stated that this resident is not one to complain unless she is in pain. She added that the resident's walking has decreased since her pain has increased. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 314) completed on 11/8/16, it was determined that for one (Resident #119) of two residents reviewed for smoking procedures, the facility did not ensure that the residential environment remained as free of accident hazards as possible. Issues included non-compliance with oxygen tanks and smoking. This is evidenced by the following: Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a progress note, dated 7/30/16, revealed that the resident confessed that he removes his oxygen while lighting his cigarette and then replaces the nasal cannula into his nose. He states that the cigarette flickers a little while smoking. This writer is very concerned for the resident's safety and educated the resident to the dangers of wearing oxygen while smoking, discussed fears that the oxygen may make the flame larger leading to third degree burns of oral pharyngeal tracheal area. Further review of a progress note, dated 8/2/16, revealed an entry that stated: 'notified by nursing that patient is going outside to smoke with oxygen on .if he wishes to go outside to smoke he will have to have nursing staff remove oxygen and re-apply upon return .explained the risks of smoking with oxygen on.' A review of the Comprehensive Care Plan for the resident dated August 2016, revealed goals/objectives including: 'compromises his safety or safety of others by going out into the parking lot to smoke with oxygen on. Interventions included the resident will sign out and remove oxygen if he goes out to smoke.' Further document review revealed the resident refused to sign the smoking policy/agreement on both 9/29/16 and 10/15/16. Interviews conducted on 11/2/16 included the following: a. At approximately 11:45 a.m., the Registered Nurse Manager (RNM) on the Bilz Unit was interviewed regarding the smoking habits of the resident. The RNM stated that the resident no longer keeps his smoking materials because he burned himself and was non-compliant with his oxygen mask. The RNM also stated that the incident involving the burn had been reported to the New York State Department of Health. b. At 2:30 p.m., the Director of Nursing (DON) provided the surveyor with documentation related to an incident involving the resident on 10/25/16. A statement completed by the DON on 10/27/16 revealed that the resident had a burning cigarette on the footrest of his motorized wheelchair as he was traveling to his room returning from the outside. The resident was then found to have a 1.5 centimeter (cm) by 1 cm fluid-filled blister on the bottom of his right foot and stated that he did not feel the cigarette burning his foot. The report also revealed that the resident is a paraplegic with limited use of his lower extremities and severe neuropathy (disease affecting nervous system). The report documented that the resident is care planned to sign out with staff upon going outside to smoke so that staff can remove/turn off his oxygen. The resident consistently chooses not to sign out or tell staff that he is going to smoke. The report documented that the resident has a long history of choosing not to be compliant with the facility smoking policy and care plan safety measures, including declining the use of a safety apron. Further review of a staff investigation statement from 10/25/16 revealed the oxygen tank was only turned off after discovery of the burning cigarette and the resident said, Don't turn my oxygen off! Interviews conducted on 11/7/16 included the following: a. At approximately 3:15 p.m., the DON stated that she was aware of the resident's non-compliance with smoking and they did not consider a wanderguard. The DON said that the resident's preferred time to smoke is after meals, and staff members in the area were supposed to watch him. b. At approximately 3:25 p.m., the Bilz Unit NM said that the resident basically has to keep his oxygen (5 liters) on at all times or his oxygen saturation concentrations will fall too low. A review of the smoking safety assessments for the resident completed in August and October of 2016 revealed the assessments did not take into consideration whether the resident had orders for oxygen, or made accommodations for the removal of oxygen when the resident chooses to smoke. (10 NYCRR 415.12(h)(1))

Based on observations, interviews, and record reviews it was determined that for one (Resident #156) of six residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime is free of unnecessary medications. Specifically, for a resident with a recent change in condition and receiving [MEDICAL CONDITION] medications, a gradual dose reduction was not attempted or a clinical contraindication was not documented. This is evidenced by the following: Resident #156 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Consultant Pharmacist/Physician Communication Form, dated 2/2/16, revealed that the resident received [MEDICATION NAME] (mood stabilizer) 250 milligrams (mg) at bedtime for [MEDICAL CONDITION] with behaviors. The morning dose was discontinued 12/9/15 and the resident had no difference in behaviors with the decrease. It is noted that the levels are sub-therapeutic and to consider further taper to assess need. The form was signed by the pharmacist and the physician/prescriber response either agreeing or disagreeing with the pharmacist recommendation was blank. A physician progress notes [REDACTED]. The assessment and plan included the resident was stable on current [MEDICAL CONDITION] medications, was end stage and receiving hospice services. Review of the Registered Nurse (RN) Hospice Note, dated 8/18/16, revealed the resident was sleeping, and the record review revealed intermittent yelling out with no pattern. Review of the progress notes, dated 8/10/16 through 8/31/16, documented three occasions when the resident yelled out and received pain medication with relief. Review of the progress notes, dated 9/1/16 through 9/30/16, revealed one occasion when the resident yelled out and received pain medication with relief. Review of the RN Hospice Note, dated 9/14/16, revealed that some days the resident is left in bed as staff are unable to arouse him. The resident has had a decrease in calling out, and the RN recommended to reevaluate the need for the current [MEDICATION NAME] dosage due to resident's increased lethargy and decreased agitation. Psychopharmacologic drug worksheets, dated 9/20/16, included [MEDICATION NAME] for depression, [MEDICATION NAME] (antipsychotic) for dementia with behavioral disturbance, and [MEDICATION NAME] (antianxiety) for severe agitation. The form documented that the medication was effective. The 'action section' and 'comment section' of the form which addresses to start, increase, discontinue or decrease the medication was blank. Physician orders dated 10/3/16 and 11/1/16, included [MEDICATION NAME] (antidepressant) 30 mg every day for depression, [MEDICATION NAME] (pain reliever) 2.5 mg three times a day, [MEDICATION NAME] 5 mg twice a day for behavioral disturbance, [MEDICATION NAME] 250 mg twice a day, [MEDICATION NAME] 2 mg daily at bed time and [MEDICATION NAME] 2 mg twice a day as needed for severe agitation. A Nurse Practioner (NP) note with a date of 10/5/16 at 10:42 a.m., revealed that staff reported the resident's yelling out behavior has decreased and now is occasional. The NP documented that the resident has Alzheimer's and [MEDICAL CONDITION] with behaviors and failed trazadone, [MEDICATION NAME] and [MEDICATION NAME]. The resident had some response to pain medication in the past and behaviors were better controlled. The plan was to continue [MEDICATION NAME], and [MEDICATION NAME]. The resident is end stage and on hospice. Review of progress notes 10/1/16 through 11/7/16 revealed on 10/13/16 that the resident yelled out at random times. On 11/2/16, the resident had facial grimacing and yelled out and received pain medication with relief. During an observation on 11/3/16 at 9:03 a.m., the resident was sitting in the chair with his eyes open, gazing towards the ceiling with his mouth wide open. The resident did not respond to verbal stimuli. During observations on 11/4/16 at 10:33 a.m. and on 11/7/16 at 8:20 a.m., the resident was sitting in the chair with his eyes closed. On 11/7/16, several staff members attempted to arouse the resident for breakfast before he opened his eyes and began to eat. In an observation on 11/7/16 at 11:04 a.m., the resident was in bed and slept through the staff performing Range of Motion exercises for the resident. At that time, the Certified Nursing Assistant (CNA) stated the resident is knocked out. Interviews conducted on 11/7/16 included the following: a. At 9:21 a.m., the Registered Nurse Manager (RNM) said the resident was last seen by psychiatry in October 2015. She said the resident has not been seen by psychiatry since he went on Hospice. The RNM stated the resident has been quieter this week. She stated when he yells out we medicate him with pain medication and he is fine. b. At 9:39 a.m., CNA #1 stated the resident yells the most when he is hungry or wet. She said when the resident is yelling they change him, offer him a snack, take him for a walk or lie him down in bed. She stated he likes music and has a rain (sound effects) box in his room. CNA #2 stated some days the resident sleeps more. She stated some days he yells in pain which we report to the nurse. c. At 1:13 p.m., the NP stated she never saw the hospice recommendations regarding reevaluating the use of [MEDICATION NAME] due to increased lethargy and decreased agitation. She said the hospice notes should be reviewed with her. d. At 3:11 p.m., the Pharmacist stated she sent the recommendation regarding the [MEDICATION NAME] on 2/2/16 and then the [MEDICATION NAME] was increased on 2/16/16. She stated the last Gradual Dose Reduction (GDR) was attempted 10/20/15. The Pharmacist stated GDRs are looked at once a year. When interviewed on 11/8/16 at 10:42 a.m., the RNM stated she does not review the hospice notes. She said the notes are supposed to be reviewed by the physician or NP. Review of the facility policy, Guidelines for Gradual Dose Reduction of Psychotherapeutic Medications, dated December 2013, documented a gradual dose reduction may be indicated when the resident's clinical condition has improved and/or stabilized, the underlying cause or the underlying causes of the original target symptoms has resolved and/or non-pharmacological interventions have been effective in reducing symptoms. The policy instructs that within the first year after the facility has initiated an antipsychotic medication the facility will attempt a GDR in two separate quarters, at least one month apart, unless clinically contraindicated. The policy documents the same instructions for GDRs with antidepressants, anxiolytics and other drugs used to stabilize mood or manage behaviors. (10 NYCRR 415.12(l)(l)(2)(i))

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 560) completed on 11/8/16, it was determined that for one (Resident #262) of two residents reviewed for medication errors, the facility did not ensure the residents were free from significant medication errors. Specifically, the resident did not receive the nebulizer treatment as ordered. This is evidenced by the following: Resident #262 was admitted [DATE] at 3:30 p.m. with [DIAGNOSES REDACTED]. The physician orders, dated 7/2/16 (5:00 p.m.), included [MEDICATION NAME] 2.5 milligram (mg)/ 3 milliliter (ml) nebulizer solution, use one vial in nebulizer every two hours. Review of two Licensed Practical Nurse (LPN) progress notes, dated 7/2/16 (9:00 p.m.) and 7/3/16 (1:30 a.m.), revealed the resident had requested and received an as needed [MEDICATION NAME] Treatment. The 1:30 a.m. treatment was requested as the resident had shortness of breath The July 2016 Medication Administration Record [REDACTED]. The medication was signed as administered on 7/3/16 (1:30 a.m. and 9:30 a.m.). A second entry on the MAR indicated [REDACTED]. During an interview on 11/4/16 at 9:58 a.m., the Nurse Manager (NM) stated the physician order [REDACTED]. The NM stated when a medication error is discovered, the nurse should initiate a medication error report. After surveyor intervention, the NM completed a medication error report and investigation. The investigation included statements from the nurses involved, however, the nurses were not available for interview. (10 NYCRR 415.12(m)(2))

Based on staff interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 604), completed on 12/7/12, it was determined that for 2 of 31 residents reviewed for care and services, facility staff failed to provide the necessary care and services to maintain residents' highest practicable physical well-being. Specifically, the facility failed to provide thorough and timely nursing and physician assessments for a resident with a significant change in condition (Resident #284), and did not adequately communicate regarding [MEDICAL TREATMENT] care needs between the facility and [MEDICAL TREATMENT] provider and did not provide thorough daily care and assessment of the [MEDICAL TREATMENT] fistula (Resident #83). This resulted in actual harm that is not immediate jeopardy for Resident #284, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #83. This is evidenced by the following: 1. Resident #284 was admitted to the facility for a planned short-term respite stay from 7/27/12 to 8/6/12 with [DIAGNOSES REDACTED]. The initial physician's orders [REDACTED]. Admission Assessments, dated 7/27/12, included a Pain Assessment, a Nursing Admission Assessment, and Physician Standing Orders. Documentation on the Pain Assessment shows that the resident had complaints of chronic/persistent pain in her legs that she described as aching upon arrival to the facility. The Nursing Admission Assessment identified positive pedal pulses. The Physician Standing orders included an order for [REDACTED].#1 gave the resident a dose of as needed Tylenol at 7:00 p.m. for complaints of foot and ankle pain with no effect. Review of the Supervisor Report Sheet for 7/28/12 revealed that the resident fell out of a recliner at 6:30 a.m. that morning and sustained bruising to her right and left elbows. There was no documentation to show that the physician was notified after the fall. No other injuries were documented. In a progress note at 8:00 p.m. that evening, LPN #2 documented that the resident's left foot was cold to touch, toes were [MEDICAL CONDITION], second toe was purple and red in color, and the resident would not bear weight on the left foot. As needed Tylenol was given with no effect. At 8:20 p.m. that evening, the Registered Nurse (RN) Nursing Supervisor documented in a progress note that the resident complained of pain in her left foot upon palpation of the top and bottom of her toes. Also, the second toe was slightly red, there was two plus [MEDICAL CONDITION] (fluid) present, pedal pulses were present, and the skin was cool to touch. In a progress note, dated 7/29/12, LPN #3 noted that the resident was given as needed Tylenol 650 mgs at 10:30 p.m. on 7/28/12, and at 2:30 a.m. on 7/29/12, and was bearing little to no weight on the left foot. LPN #4's progress note and the Supervisor's Report Sheet for 7/31/12 both show that the resident continues to receive as needed Tylenol for leg pain and is not bearing weight on the left leg. Review of the Nurse Practitioner's (NP) Assessment, dated 8/1/12, revealed that the NP was asked to evaluate the resident's pain related to a swollen, red, and warm right foot (see NP interview 12/5/12 at 1:45p.m.) over the past four days. The NP noted that the resident's right foot was red, warm, [MEDICAL CONDITION], and painful to the touch. The third, fourth, and fifth toes were cyanotic (bluish color due to lack of oxygen). The NP's problem list included questionable vascular insufficiency. The NP ordered a podiatry visit, an increase in [MEDICATION NAME] dose (for gout), and a narcotic medication for pain. In a progress note, dated 8/2/12, LPN #3 recorded the presence of a blister above the third digit of the left foot and continued complaints of pain. The podiatrist ordered an x-ray to rule out a [MEDICAL CONDITION] foot. On 8/3/12, the podiatrist documented in a progress note that the x-ray of the left foot was negative for a fracture. Also, she saw the resident briefly on 8/2/12 but did not physically examine the foot. Her examination on 8/3/12 revealed non palpable pulses in the left foot and greatly delayed blood flow in the first, third, fourth, and fifth toes, extreme pain, four plus [MEDICAL CONDITION] of the left foot, and inability to bear weight. The assessment was noted as acute phlebitis (blood clot) and the plan was to transfer the resident to the emergency room for evaluation and treatment. Interviews conducted on 12/5/12 revealed the following: a. At 10:00 a.m., the RN evening supervisor said that when she assessed the resident on 7/28/12, she saw that the resident was taking medications for gout ([MEDICATION NAME] and [MEDICATION NAME]). She did not feel she needed to contact the physician but did pass the information along in report. The RN evening supervisor explained that medical does not routinely see respite residents, but medical should have been notified if pain medication is ineffective. b. At 11:30 a.m., the Admission Intake Specialist stated a resident admitted for respite care is treated as a traditional admission. The resident should be admitted with recent history and physical, and a list of current medication completed by the primary care physician. The resident can be seen by the facility's physician on an as needed basis. c. At 1:45 p.m., the NP said that respite care residents are only seen for acute problems. She said that she charts by exception so she would not have documented pulses, unless there was a problem. She said that the physician should have been notified when the pain medication was not effective, and the coldness in the feet is concerning. The NP verified that her assessment dated [DATE] was of the left foot, not right foot. When interviewed on 8/6/12 at 1:10 p.m., the podiatrist said that she went in to cut the resident's toenails on 8/2/12, and when she found the resident in considerable pain, asked the NP to order x-rays. She said she did not touch the foot or check pulses at that time. The podiatrist stated that upon examination on 8/3/12 the resident's foot was mottled, swollen, and had no pulses. She then wrote orders to send the resident to the hospital. Interviews conducted on 12/7/12 are as follows: a. At 8:30 a.m., the NP said that the podiatrist reported to her that she would like an x-ray to rule out a fracture, osteo[DIAGNOSES REDACTED], or any other underlying issue. She said that she does not remember hearing about blisters on the resident's toes. She said that she and the Medical Director saw the resident together, and the plan was to let the gout flare up, calm down, and then get vascular involved if needed. b. At 8:45 a.m., LPN #1 was interviewed by telephone and said that the resident would not bear weight. She said that respite residents have their own primary physician. She said that the facility's medical staff writes only medication orders. c. At 9:10 a.m., the Director of Nursing said that respite residents are not assigned a primary physician while at the facility, as they are not provided medical services. She said if there was an acute change on the weekend with the resident's foot, then she would have expected the resident be sent to ED. She said that the RNM or RN/CC on the unit should have looked at the resident's foot at some point based on the information in the medical record and on the Supervisor Report Sheet. d. At 1:20 p.m., the Medical Director explained that he was the attending physician for this resident because the resident's primary care physician did not have rights to practice in the facility. Also, the facility's Medical Notification Guidelines, which all staff has, are the same for all residents, and for this resident there could have been more notification. The Medical Director said that medical should have seen this resident when she was not responding to the pain medication. He was aware that the NP believes he saw the resident, but he cannot be sure because there is no documentation. The facility's policy, "Respite Care," most recently dated December 2011, directs staff to use the same nursing admission guidelines as a long term care resident. Additionally, if the resident's physician does not have Wayne Health Care privileges, the Medical Director will assume the resident's care upon admission. The facility's policy, "Guidelines for Notification of Medical Staff," last dated September 2012, lists falls, [MEDICAL CONDITION], and increase in agitation under, "change in condition," and give time frames for when medical should be called to address the concerns. 2. Resident #83 has [DIAGNOSES REDACTED]. The Comprehensive Care Plan (CCP), dated 2/12/12, included to monitor the fistula insertion site daily for redness, swelling, and to complete the [MEDICAL TREATMENT] Documentation Sheet before and after treatment. The [MEDICAL TREATMENT] Documentation Sheet was completed by facility staff three days a week. The only [MEDICAL TREATMENT] treatment sheets completed by the [MEDICAL TREATMENT] center after [MEDICAL TREATMENT] sessions in the facility's record were dated 2010. There was no other documentation in the record to show that the fistula insertion site was monitored on non [MEDICAL TREATMENT] days. Interviews conducted on 12/6/12 are as follows: a. At 12:45 p.m., the day LPN said the [MEDICAL TREATMENT] Documentation Sheet is sent to [MEDICAL TREATMENT] and the completed form is returned to the facility. She was unable to locate any documentation from [MEDICAL TREATMENT]. Also, there is no order to check the fistula site for thrill and bruit (sounds used to evaluate potency of the tube). However, she occasionally checks the fistula site and records the information in the progress notes. b. At 1:20 p.m., the NP said that she would expect nursing to follow the guidelines for care provided by the hemodialyisis unit. At that time, the NP learned that the facility does not have guidelines from the [MEDICAL TREATMENT] center. The NP said that she would expect the thrill and bruit be checked at least daily. c. At 2:35 p.m., the RN Manager said that the fistula site should be monitored daily for thrill and bruit, bleeding, and signs of infection. She explained that the [MEDICAL TREATMENT] Documentation Sheets are sent with the resident to the [MEDICAL TREATMENT] center three times a week, completed by [MEDICAL TREATMENT], and returned to the facility. The RN Manager was unable to locate any [MEDICAL TREATMENT] flow sheets completed by [MEDICAL TREATMENT] in the last two years. d. At 3:10 p.m., in a telephone interview, the [MEDICAL TREATMENT] center RN said that the center does not send out guidelines. She said that every nursing facility should have their own policies and procedures for monitoring the fistula sites, and as a [MEDICAL TREATMENT] nurse, that the fistula should be monitored for thrill and bruit and the site monitored for bleeding and signs of infection every shift. The [MEDICAL TREATMENT] center RN reported that the [MEDICAL TREATMENT] treatment sheet was faxed to the facility after every session, but the facility indicated that they were not receiving the completed form. The [MEDICAL TREATMENT] nurse said that a few days ago, the [MEDICAL TREATMENT] center requested that the facility send a [MEDICAL TREATMENT] Communication Form with the resident, which is completed by the center and returned to the facility. e. At 3:15 p.m., the evening LPN said that the resident returns from [MEDICAL TREATMENT] with paperwork. She was unable to locate any of the paperwork. She said that she cares for the resident occasionally and upon his return from [MEDICAL TREATMENT], she checks his dressing for any signs of bleeding and thrill and bruit. The LPN said on [MEDICAL TREATMENT] days, she documents that information on the [MEDICAL TREATMENT] documentation sheet. She explained in the past, when the resident was on another unit, all of the [MEDICAL TREATMENT] information was on the Treatment Administration Record. f. At 2:35 p.m., the Director of Nursing said that the facility does not have a policy for [MEDICAL TREATMENT] or [MEDICAL TREATMENT] care. She said that the physician orders [REDACTED]. (10 NYCRR 415.12, 410.2)