How many inspection deficiencies does NORTHERN RIVERVIEW HEALTH CARE, INC have?

NORTHERN RIVERVIEW HEALTH CARE, INC has 40 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at NORTHERN RIVERVIEW HEALTH CARE, INC?

NORTHERN RIVERVIEW HEALTH CARE, INC has a two-star staffing rating from CMS with 0.41 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is NORTHERN RIVERVIEW HEALTH CARE, INC located?

NORTHERN RIVERVIEW HEALTH CARE, INC is located in HAVERSTRAW, NY. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does NORTHERN RIVERVIEW HEALTH CARE, INC have?

NORTHERN RIVERVIEW HEALTH CARE, INC has 182 certified beds.

Who owns NORTHERN RIVERVIEW HEALTH CARE, INC?

NORTHERN RIVERVIEW HEALTH CARE, INC is a non profit - corporation facility and operates independently (not part of a chain).

NORTHERN RIVERVIEW HEALTH CARE, INC

Name: NORTHERN RIVERVIEW HEALTH CARE, INC
Address: 87 SOUTH ROUTE 9W, HAVERSTRAW, NY, 10927, US
Telephone: (845) 429-5381
Rating: 1.0

87 SOUTH ROUTE 9W, HAVERSTRAW, NY 10927 · (845) 429-5381

Non profit - Corporation 182 Beds Independent Data: November 2025

Trust Grade

45/100

#540 of 594 in NY

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Last Inspection: February 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Northern Riverview Health Care, Inc. has a Trust Grade of D, indicating below average performance with some significant concerns to consider. It ranks #540 out of 594 nursing homes in New York, placing it in the bottom half of facilities statewide, and #8 out of 10 in Rockland County, meaning only two local options are worse. The facility shows an improving trend, having reduced reported issues from 15 in 2024 to 6 in 2025, which is a positive sign. Staffing is a strength with an 18% turnover rate, well below the state average, although they received a below-average 2 out of 5 stars for staffing overall. Notably, the facility has had no fines, which is good, but there are serious concerns regarding care, such as residents reporting being short-staffed, slow response times to call bells, and a specific incident where a resident alleged abuse that was not reported as required by law. Overall, while there are some strengths in staffing and an improving trend, the facility has significant weaknesses that families should carefully consider.

Trust Score: D
In New York: #540/594
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 18% annual turnover. Excellent stability, 30 points below New York's 48% average. Staff who stay learn residents' needs.
Penalties: No fines on record. Clean compliance history, better than most New York facilities.
Skilled Nurses: Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 40 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 15 issues

2025: 6 issues

The Good

Low Staff Turnover (18%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (18%)
30 points below New York average of 48%

Facility shows strength in staff retention, fire safety.

The Bad

1-Star Overall Rating

Below New York average (3.0)

Significant quality concerns identified by CMS

The Ugly 40 deficiencies on record

May 2025 6 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY00334577) the facility did not ensure the residents right to a dignified existence inside the facility for 1 out of 3 residents (Resident #3) reviewed for dignity. Specifically, on 2/26/2024 Resident #4 who was Resident #3's neighbor, went to Resident #3's room unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and crying about Resident #4's behavior. The Findings are: The facility Residents Rights policy last revised 5/28/2024 documented Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, to be treated with respect, kindness, and dignity and be free from abuse, neglect, misappropriation of property, and exploitation. Resident #3 was admitted with diagnoses including but not limited to Dementia, Major Depressive Disorder and Personal History of COVID-19. Review of an admission Minimum Data Set, dated [DATE] documented Resident #3 had moderate cognitive impairment. Resident #3 used a wheelchair for mobility, requires set up assistance with eating, moderate assistance with toileting, bed mobility and transferring. Review of a risk for abuse care plan last revised 4/9/2024 documented Resident #3 was at risk related to their wandering behavior. Interventions listed included monitor resident for signs/symptoms of abuse and report to the facility's abuse officer and medical provider. Review of a mood symptoms care plan last updated 2/26/2024 documented Resident #3 displayed mood symptoms as evidenced by crying outbursts, verbalizing of being afraid, I don't want them to rape me and complained of a male resident exposing themself to them. Interventions listed included encourage family/informal support involvement Review of the investigative summary dated 2/26/2024 documented on 2/26/2024 it was reported to the Director of Nursing that Resident #4 had exposed themself to Resident #3 and holding their penis asked how they thought of their penis. It was reported that Resident #3 was upset and crying about Resident #4's behavior. During an interview on 4/11/2025 at 1:35 PM Resident #3 stated it was a long-time ago, but Resident #4 was gay. Resident #3 stated they used to talk to Resident #4 from time to time and they were good friends. Resident #3 stated Resident #4 was their neighbor, and the resident came to their room, looked at them and unzipped their pants and then walked away. Call placed to the Director of Nursing on 5/14/2025 at 12:45 PM and 5/23/2025 at 11:14 AM, 11:17 AM and 1:04 PM, unable to reach for interview. 10 NYCRR 415.5(a)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY00334577), the facility did not ensure the residents right to be free from abuse for 1 out of 3 residents (Resident #3) reviewed for abuse. Specifically, on 2/26/2024 Resident #4, who was Resident #3's neighbor, went to Resident #3's room unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and was crying about Resident #4's behavior and verbalized a fear of being raped. Subsequently, Resident #3's room was changed to another unit. The findings are: The facility Abuse policy last reviewed 6/1/2024 documented the facility prohibits the mistreatment, neglect and abuse of residents/patients by anyone but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse. Mental/Emotional abuse is the use of verbal and nonverbal; conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Mental abuse also included 1)Resident #3 was admitted with diagnoses including but not limited to Dementia, Major Depressive Disorder and Personal History of COVID-19. An admission Minimum Data Set, dated [DATE] documented Resident #3 had moderate cognitive impairment. Resident #3 used a wheelchair for mobility, required set up assistance with eating, moderate assistance with toileting, bed mobility and transferring. Review of a risk for abuse care plan last revised 4/9/2024 documented Resident #3 was at risk related to their wandering behavior. Interventions listed included monitor resident for signs/symptoms of abuse and report to the facility's abuse officer and medical provider. Review of a mood symptoms care plan last updated 2/26/2024 documented Resident #3 displayed mood symptoms as evidenced by crying outbursts, verbalizing of being afraid, I don't want them to rape me and complained of a male resident exposing themself to the resident. Interventions listed included encourage family/informal support involvement. 2) Resident #4 was admitted to the facility with diagnoses including but not limited to Dementia, Schizoaffective Disorder and Epilepsy. A Quarterly Minimum Data Set, dated [DATE] documented Resident #4 was cognitively intact with no behaviors noted. The resident required a wheelchair or a walker for locomotion, independent with eating, bed mobility and transfers, required supervision for toileting. Review of a behavior care plan last revised 1/31/2022 documented Resident #4 was sexually inappropriate toward their roommate. Resident #4 was also documented as sexually inappropriate towards female staff and residents. Interventions listed included contract with resident as needed, determine cause of behavior and remove resident, document all behaviors and attempt to identify pattern to target interventions, initiate psychiatric and psychology evaluation as needed and notify physician of inappropriate or negative behavior or activity. Review of the investigative summary dated 2/26/2024 documented, on 2/26/2024 it was reported to the Director of Nursing that Resident #4 had exposed themself to Resident #3 and holding their penis asked Resident #3 how they thought of their penis. It was reported that Resident #3 was upset and crying about Resident #4's behavior. Review of an interdisciplinary team meeting note dated 2/26/2024 documented a care plan/high risk meeting was held with nursing and social services. Resident #3's representative stated Resident #3 called them on 2/25/2024 and mentioned an incident that took place, where Resident #4, their neighbor, came to their room and pushed them, pulled down their pants and exposed their genitalia. The Social Worker was unaware of such an incident, but the Social Worker explained that they will investigate further. The Director of Nursing went a step further, by obtaining a confession from Resident #4. Resident #4 admitted they did expose themself to Resident #3, but they did not touch the resident in any way. For safety purposes and precaution, Resident #3 was offered and agreed to be transferred to another floor all together. Resident #3 was relieved to be transferred, and their representative also agreed that the move was adequate and appropriate. There was no physical contact as per Resident #3 from Resident #4, however Resident #3 complained about being afraid of being raped. Review of a Psychology consult dated 2/27/2024 documented Resident #3 was referred by the nursing staff to be seen, to assess for suicidal ideation due to being distressed over the incident that occurred with Resident #4. Resident #3 was alert and oriented to person and time. The resident's thought process was disorganized, but they denied any suicidal/homicidal ideation. Resident #3 was involved in an incident where Resident #4 flashed them and reported they were upset at first but were happy when they were transferred to a different floor. The resident denied making any statements of hurting themself. The plan documented Resident #3 did not have the capacity to benefit from psychological services and was no danger to their self or others. Review of a Psychiatry consult dated 3/1/2024 documented Resident #3 was seen due to fear/emotionally labile. Resident #3 was noted to be anxious and depressed. A call was placed to the Director of Nursing on 5/14/2025 at 12:45 PM and 5/23/2025 at 11:14 AM, 11:17 AM and 1:04 PM, but unable to reach for interview. 10 NYCRR 415.4(b)(1)(i)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during an abbreviated survey (NY00355946, NY00334577, NY00336626), the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility also did not report the results of all investigations to the New York State Department of Health in accordance with State law, within 5 working days of the incident for 3 out of 3 residents (Resident #1, Resident #3, Resident #5) reviewed for abuse. Specifically, (1) on 9/27/2024 Resident #1 reported to their representative that staff had beat them up while in the dining room the day before. The Administrator was not made aware of the allegation until 9/30/2024 and there was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health; (2) On 2/26/2024 Resident #4 went to their neighbor Resident #3's room and unzipped their pants and exposed themself to Resident #3. Resident #3 was upset and crying due to Resident #4's behavior. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health; (3) On 3/19/2024 Resident #5 complained that Certified Nurse Aide #5 on the 7 AM to 3 PM shift, showed no empathy when they told them their spouse had passed away years ago. Resident #5 also informed other staff that the Certified Nurse Aide #5 was kind of rough with them and described them as a goliath to other employees. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health. The findings are: The facility Abuse policy last reviewed 6/1/2024 documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. The Administrator and Director of Nursing are responsible for investigation and reporting. Report results of investigation to the proper authorities as required by State law. Failure to report to required Regulatory Agencies in the capacity of a facility administrator could result in termination. 1) Resident #1 had diagnoses including Chronic Obstructive Pulmonary Disease, Schizophrenia and Major Depressive Disorder. A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had moderate cognitive impairment. The resident required a wheelchair for locomotion, maximal assistance with eating, dependent for toileting, bed mobility and transfers. Review of the undated facility investigation form documented Resident #1's representative stated they reported the incident to the Department of Health because they were frustrated and felt the two Registered Nurses were dismissive and unprofessional. The investigative conclusion dated 10/5/2024 documented there is no evidence to substantiate the allegation, investigation revealed no cause to believe that the resident had been abused as alleged. Review of the complaint submission report revealed the incident occurred on 9/26/2025, staff were first made aware on 9/27/2024 at 6:00 AM, and the Administrator was made aware on 9/30/2024 at 10:30 AM. There was no documented evidence of an investigative conclusion being submitted to the New York State Department of Health. 2) Resident #3 had diagnoses including but not limited to Dementia, Major Depressive Disorder and Personal History of COVID-19. Review of an admission Minimum Data Set, dated [DATE] documented Resident #3 had moderate cognitive impairment. Resident #3 used a wheelchair for mobility, required set up assistance with eating, moderate assistance with toileting, bed mobility and transferring. 3) Resident #4 had diagnoses including but not limited to Dementia, Schizoaffective Disorder and Epilepsy. A Quarterly Minimum Data Set, dated [DATE] documented Resident #4 was cognitively intact with no behaviors noted. The resident required a wheelchair or a walker for locomotion, independent with eating, bed mobility and transfers, required supervision for toileting. Review of the investigative summary dated 2/26/2024 documented on 2/26/2024 it was reported to the Director of Nursing that Resident #4 had exposed themself to Resident #3 and while holding their penis asked what they thought of their penis. It was reported that Resident #3 was upset and crying about Resident #4's behavior. Resident #3 did not report this to the nurses or the certified nurse aides. Resident #3 and Resident #4 both confirmed that no touching had occurred. The investigative conclusion dated 3/3/2024 documented there is no evidence to support that any alleged resident Abuse may have occurred. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health. 4) Resident #5 had diagnoses including but not limited to Muscle Weakness, Major Depressive Disorder and Anxiety. A Quarterly Minimum Data Set, dated [DATE] documented the resident was cognitively intact with no behaviors noted. The resident required a wheelchair for locomotion, set up assistance with eating, moderate assistance with toileting and transfers and supervision with bed mobility. Review of a facility full Quality Assurance report dated 3/20/2024 documented on 3/19/2024 Resident #5 complained that Certified Nurse Aide #5 on the 7 AM to 3 PM shift showed no empathy when they told them their spouse had passed away years ago. Resident #5 also informed other staff that the Certified Nurse Aide #5 was kind of rough with them and described them as a goliath to other employees. Review of the investigation form dated 3/25/2024 documented Resident #5's complaint was investigated and concluded as no evidence of abuse, neglect or mistreatment, resident wishes to not have Certified Nurse Aide #6 and this will be honored. No trauma or any other negative effect observed at this time. Resident #5's representatives informed of the outcome of the investigation. There was no documented evidence of the investigative conclusion being submitted to the New York State Department of Health. During an interview on 4/14/2025 at 6:00 PM, the Director of Nursing stated they are responsible for reporting incidents to the Department of Health. The Director of Nursing stated they also submit the 5-day investigative conclusion but was unaware that the 5-day conclusion was not submitted. The Director of Nursing stated they believe when the incident occurred it was shabbat, but the Administrator is informed of any incident that happens before sundown, as soon as shabbat ends. The Director of Nursing stated Resident #1 reported to their representative that the day before they had gotten beat up by a staff in the dining room. The Director of Nursing stated they reported this case because, Resident #1's representative had called it in so they did not want some to tell them they should have reported the incident to the Department of Health. During an interview on 5/9/2025 at 12:22 PM, the Administrator stated all reportable incidents are completed and submitted by them or the Director of Nursing and most senior person if they are unavailable. The Administrator stated they are informed of all reportable incidents and if an incident occurs on the [NAME], the Director of Nursing does the reporting to the Department of Health. The Administrator stated during [NAME] they are still informed timely via text message, and they are aware as soon as they turn their cellphone back on. The Administrator stated the 5-day investigative conclusions are submitted by them or the Director of Nursing. The Administrator stated the Director of Nursing keeps a record of all the reportable information. The Administrator stated they do not remember when they were informed about the incident reported on 9/26/2024 with Resident #1 and they do not recall the investigative conclusion not being submitted to the New York State Department of Health. The Administrator stated they do not remember Resident #5's case either and they do not recall the investigative conclusion not being submitted to the New York State Department of Health. 10NYCRR 415.4(b)(1)(ii)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during an abbreviated survey (NY00355946, NY00334577), the facility did not ensure the comprehensive care plan was updated and revised for 3 out of 3 residents (Resident #1, Resident #3, Resident #4) reviewed for care planning. Specifically, (1) On 9/27/2024 Resident #1 reported to their representative that they were beaten on 9/26/2024 by staff in the dining room. Review of Resident #1's abuse care plan revealed it was not updated to reflect the allegation of abuse (2) On 3/26/2024 Resident #4 exposed themself to Resident #3. Resident #3's abuse care plan was not updated to reflect this allegation and Resident #4's behavior care plan was not updated to reflect their behavior. The findings are: The facility Comprehensive Care Plan policy last reviewed 8/2/2024 documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition. 1) Resident #1 had diagnoses including Chronic Obstructive Pulmonary Disease, Schizophrenia and Major Depressive Disorder. A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had moderate cognitive impairment. The resident required a wheelchair for locomotion, maximal assistance with eating, dependent for toileting, bed mobility and transfers. A risk for abuse care plan care plan last revised 6/24/2022 documented Resident #1 was at risk for abuse to due dependence on staff for activities of daily living. Interventions listed included assess resident for abuse/neglect and report to appropriate resources, investigate all allegations of abuse and neglect promptly, provide support and ensure free from abuse, report to physician and initiate assessment and monitor resident for signs and symptoms of abuse and report to the facility's abuse officer and medical provider. Resident #1's abuse care plan was not updated to reflect the allegation made on 9/27/2024. 2) Resident #3 had diagnoses including but not limited to Dementia, Major Depressive Disorder and Personal History of COVID-19. Review of an admission Minimum Data Set, dated [DATE] documented Resident #3 had moderate cognitive impairment. Resident #3 used a wheelchair for mobility, requires set up assistance with eating, moderate assistance with toileting, bed mobility and transferring. Review of a risk for abuse care plan last revised 4/9/2024 documented Resident #3 was at risk related to their wandering behavior. Interventions listed included monitor resident for signs and symptoms of abuse and report to the facility's abuse officer and medical provider. Resident #3's abuse care plan was not updated to reflect the reported allegation made on 3/26/2024. 3) Resident #4 had diagnoses including but not limited to Dementia, Schizoaffective Disorder and Epilepsy. A Quarterly Minimum Data Set, dated [DATE] documented Resident #4 was cognitively intact with no behaviors noted. The resident required a wheelchair or a walker for locomotion, independent with eating, bed mobility and transfers, required supervision for toileting. Review of a behavior care plan last revised 1/31/2022 documented Resident #4 was sexually inappropriate toward their roommate. Resident #4 was also documented as sexually inappropriate towards female staff and residents. Interventions listed included contract with resident as needed, determine cause of behavior and remove resident, document all behaviors and attempt to identify pattern to target interventions, initiate psychiatric and psychology evaluation as needed and notify physician of inappropriate or negative behavior or activity. Resident #4's behavior care plan was not updated to reflect exposing their self to Resident #3 on 3/26/2024. During an interview on 4/11/2025 at 1:50 PM, Registered Nurse #1 stated a Unit Manager, Assistant Director of Nursing or the Director of Nursing should update the residents care plans regarding the allegation. Registered Nurse #1 stated the care plan that would have been updated regarding this incident would be the confabulating care plan and they did not update the abuse care plan that day, stated the resident has a confabulation care plan in place. During an interview on 4/14/2025 at 5:30 PM, the Assistant Director of Nursing stated the care plans are completed quarterly and as needed. The Assistant Director of Nursing stated the Unit Managers are responsible for updating the care plans, but they and the Director of Nursing update the care plans as well. The Assistant Director of Nursing stated the social worker should update the care plans for abuse. The Assistant Director of Nursing stated Resident #1's behavior care plan should have been updated, as the allegation is a behavior. The Assistant Director reviewed Resident #1's care plans and stated they should have updated the abuse care plan due to the resident made the allegation regarding abuse initially. 10 NYCRR 415.11 (c)(2)(i-iii)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY00373143, NY00352914), the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal care for 2 out of 3 residents (Resident #2, Resident #7) reviewed for activities of daily living. Specifically, (1) Resident #2 had a known history of bladder and bowel incontinence and was dependent for toileting. Review of Resident #2's Certified Nurse Assistant documentation for June 2024 revealed the bladder and bowel incontinence care was not signed by direct care staff was not provided on 5 occasions. Review of Resident #2's Certified Nurse Assistant documentation for July 2024 revealed the bladder and bowel incontinence care was not signed by direct care staff,on 7 occasions; (2) Resident #7 had a known history of bladder and bowel incontinence and was dependent for toileting. Review of Resident #7's Certified Nurse Assistant documentation for July 2024 revealed bladder and bowel incontinence care was not signed by direct care staff, indicating care was not provided on 4 occasions. Review of Resident #7's Certified Nurse Assistant for August 2024 revealed the bladder and bowel incontinence care was not signed by direct care staff, indicating care was not provided on 14 occasions. The findings are: The facility Activities of Daily Living policy last revised 2/28/2025 documented the facility shall provide residents with Activities of Daily Living (ADL) care and support in accordance with current standards of practice, State and Federal regulations and are based on the resident's assessed needs, personal preferences and goals of care. Activities of daily living care will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, that includes but is not limited to supervision and assistance with elimination (toileting) and incontinence care. 1) Resident #2 had diagnoses including but not limited to Parkinson's disease, Dementia and Portal Hypertension. A 5-day Medicare Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment. The resident required a wheelchair for locomotion, required moderate assistance with eating, dependent for toileting, bed mobility and transfers. Resident #2 was always incontinent of bladder and bowel. Review of a bladder incontinence care plan initiated 5/17/2024 documented Resident #2 had bladder incontinence related to benign prostatic hypertrophy and impaired cognition. Interventions listed included apply incontinence device as identified as appropriate and check and provide toileting care every two to four hours as tolerated. Review of Resident #2's Certified Nurse Assistant accountability for June 2024 revealed bladder and bowel incontinence care was not signed by direct care staff as being provided on 5 occasions: 7 AM to 3 PM shift-6/14/2024, 6/28/2024, 6/30/2024, on the 3 PM to 11 PM shift-6/4/2024, 6/30/2024. Review of Resident #2's Certified Nurse Assistant accountability for July 2024 revealed bladder and bowel continence care was not signed by direct care staff as being provided on 7 occasions: 7 AM to 3 PM shift-7/14/2024, 7/18/2024, 7/28/2024 and 7/31/2024, on the 11 PM to 7 AM shift on 7/6/2024, 7/7/2024 and 7/21/2024. 2) Resident #7 had diagnoses including but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Difficulty Walking and Anxiety Disorder. An admission Minimum Data Set, dated [DATE] documented the residents was cognitively intact. The resident had an impairment on one side of the upper and lower extremity and required a wheelchair for locomotion. The resident required supervision for eating, moderate assistance for bed mobility and was dependent for toileting and transfers. Resident #7 was always incontinent on bladder and bowel. Review of a bladder and bowel incontinence care plan initiated 7/19/2024 documented Resident #7 was incontinent related to renal and rectal sphincter dysfunction associated with cerebrovascular accident and a traumatic brain injury. Interventions listed included apply incontinence device as identified as appropriate and check and provide toileting care every two to four hours as tolerated. Review of Resident #7's Certified Nurse Assistant accountability for July 2024 revealed bladder and bowel incontinence care was not signed by direct care staff as being provided on 4 occasions: on 7/26/2024 and 7/31/2024 during the 7 AM to 3 PM shift, and on 7/7/2024 and 7/13/2024 during the 3 PM to 11 PM shift. Review of Resident #7's Certified Nurse Assistant accountability for August 2024 revealed bladder and bowel continence care was not signed by direct care staff as being provided on 14 occasions: on 8/5/2024, 8/7/2024, 8/8/2024, 8/9/2024, 8/10/2024, 8/12/2024, 8/15/2024, 8/16/2024, 8/18/2024 and 8/31/2024 during the 7 AM to 3 PM shift, and on 8/10/2024, 8/12/2024, 8/21/2024 and 8/25/2024 during the 3 PM to 11 PM shift. During an interview on 4/14/2025 at 2:22 PM, Registered Nurse #1 stated they, the Director of Nursing and the Assistant Director of Nursing all review the Certified Nurse Assistant accountability documentation. Registered Nurse #1 stated the documentation should be checked every day at the end of each shift to ensure it is completed. Registered Nurse #1 stated they can check their dashboard to see the Medication Administration Record, Treatment Administration Record and Certified Nurse Assistant are completed and if they see a missing signature they will call the Certified Nurse Assistant and ask why they did not sign, if staffing was the issue or what occurred. Registered Nurse #1 stated sometimes the Certified Nurse Assistants are short staffed, and they must split an assignment, so additional residents will be put on their assignments. Registered Nurse #1 stated they also report this to the Assistant Director of Nursing and the Director of Nursing. During an interview on 4/14/2025 at 5:30 PM, the Assistant Director of Nursing stated they go to Point Click Care (the electronic medical record) and check the documentation floor by floor to see what tasks need to be done at the end of the day shift. The Assistant Director of Nursing stated they then call the receptionist and request that they make an announcement to inform staff that documentation needs to be completed. The Assistant Director of Nursing stated the supervisor should be monitoring this documentation daily and the unit managers rotate as supervisor during the week. The Assistant Director of Nursing stated they always go and check the electronic medical record for them. The Assistant Director of Nursing stated the Administrator should oversee the supervisors on the evening and the night shift. The Assistant Director of Nursing stated sometimes on the weekend they will call the supervisor on the 3 PM to 11 PM shift and remind them to have their staff complete the documentation. The Assistant Director of Nursing stated the education is done online, and they will reinforce and provide refresher classes as needed. The Assistant Director of Nursing stated there is currently no disciplinary action being given for not completing documentation. During an interview on 4/14/2025 at 6:00 PM, the Director of Nursing stated the Certified Nurse Assistant documentation is monitored all the way from the corporate level and the Certified Nurse Assistants are reminded from 2:00 PM to complete the documentation, but they still do not complete them. The Director of Nursing stated this is an issue they are working on. The Director of Nursing stated the Certified Nurse Assistants receive a written warning if they do not complete the documentation. The Director of Nursing stated they tell the staff if they do not sign their documentation then they did not do the job. 10 NYCRR 415.12(a)(3)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on record review and interview during an abbreviated survey (NY00373143) the facility did not ensure that sufficient nursing staff was consistent for residents according to the daily staffing needs. Certified nurse aide staff levels were frequently below the levels determined by the facility to be necessary to meet the needs of the residents. Specifically, review of the facility daily staffing sheets for July 2024 and August 2024 revealed staffing was not adequate across various shifts, on the first floor, based on the unit needs and provider average ratio levels documented in the facility assessment. The findings are: The facility Staffing Hours policy last revised 4/2025 documented the facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Certified nurseing assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. Review of the daily staffing schedule revealed the first floor staffing in July 2024 on the following dates and shifts: 7 AM to 3 PM shift-3 certified nurse aides-7/7/2024, 7/14/2024, 7/15/2024, 7/21/2024, 7/27/2024, 7/28/2024, 7/29/2024; 4 certified nurse aides-7/1/2024, 7/2/2024, 7/6/2024, 7/8/2024, 7/10/2024, 7/13/2024, 7/12/2024, 7/16/2024, 7/18/2024, 7/19/2024, 7/20/2024, 7/22/2024, 7/23/2024, 7/24/2024, 7/26/2024, 7/30/2024 3 PM to 11 PM shift-2 certified nurse aides-7/4/2024, 7/13/2024, 7/14/2024; 3 certified nurse aides-7/5/2024, 7/6/2024, 7/9/2024, 7/15/2024, 7/21/2024, 7/23/2024, 7/27/2024, 7/28/2024 11 PM to 7 AM shift-No certified nurse aides-7/18/2024; 1 certified nurse aide-7/1/20/2024, 7/4/2024, 7/5/2024, 7/14/2024, 7/20/2024, 7/22/2024, 7/28/2024 Review of the daily staffing schedule revealed the first floor staffing in August 2024 on the following dates and shifts: 7 AM to 3 PM shift- 2 certified nurse aides- 8/4/2024; 3 certified nurse aides-8/11/2024, 8/16/2024, 8/18/2024, 8/24/2024, 8/25/2024, 8/26/2024, 8/31/2024; 4 certified nurse aides- 8/3/2024, 8/5/2024, 8/6/2024, 8/7/2024, 8/8/2024, 8/9/2024, 8/10/2024, 8/12/2024, 8/13/2024, 8/15/2024, 8/17/2024, 8/19/2024, 8/20/2024, 8/21/2024, 8/27/2024, 8/28/2024 8/30/2024 3 PM to 11 PM shift-2 certified nurse aides- 8/25/2024; 3 certified nurse aides-8/5/2024, 8/7/2024, 8/10/2024, 8/11/2024, 8/22/2024, 8/26/2024, 8/28/2024, 8/31/2024 11 PM to 7 AM shift-1 certified nurse aide-8/5/2024, 8/6/2024, 8/7/2024, 8/8/2024, 8/10/2024, 8/11/2024, 8/16/2024, 8/19/2024, 8/25/2024 During an interview on 5/9/2025 at 12:22 PM the Administrator stated staffing in the facility is presently adequate. There were staffing issues in the past, but it has improved. During an interview on 5/9/2025 at 1:53 PM the Human Resources Director, stated they also do the staffing for the facility. The Human Resources Director stated staffing for the first floor is as follows: First floor: 7 AM to 3 PM shift -2 nurses, 5 certified nurse aides; 3 PM -11 PM shift -2 nurses, 4 certified nurse aides 11 PM to 7AM shift-1 nurse, 2 certified nurse aides. The Human Resources Director stated there was a staffing grid they used when they began their position which indicated the provider average ratio levels for the units. Currently agency staff are used to supplement staff callouts in the facility. When they began working in the facility, they did not have a lot of certified nurse aides. The Human Resources Director stated there has been a definite improvement in the number of certified nurse aides in the facility since then. The Human Resources Director stated the facility schedules run on a weekly basis and the agency staff are used when there is a call out. The Human Resources Director stated they use an application called on shift, which shows them how the staffing should be in the facility and the staffing requirements on each floor. During a follow up interview on 5/9/2025 at 2:25 PM the Administrator stated the staffing provider average ratio levels they provided the surveyor are from the facility assessment, and those are the minimum levels. The Administrator stated they will forward a copy of the provider average ratio levels used by the facility for the daily scheduling. On 5/9/2025 the Administrator provided an excel spread sheet of the provider average ratio levels required for nursing staff which reflected staffing for the first floor as follows: Licensed Practical Nurse day shift-2, evening shift-2 and night shift-1; certified nurse aides day shift-5, evening shift-4 and night shift-2. 10 NYCRR 415.13(a)(1)(i-iii)

Feb 2024 15 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, it was determined for 1 of 7 residents (Resident #151) reviewed for dignity, the facility did not ensure all residents had the right to a dignified existence. Specifically, Resident #151 reported Staff #35 (Certified Nurse Aide) spoke to her in a derogatory manner on more than one occasion and Staff #35 was observed stating please to Resident #151 after Resident #151 made two requests for ice. Findings include: Resident #151 was admitted with diagnoses including Heart Failure, Non-Alzheimer's Dementia, and Adjustment Disorder. The 8/1/23 comprehensive care plan titled 'At Risk for Abuse' documented the resident was at risk for misappropriation, neglect, abuse and or exploitation. Interventions included monitor the resident for signs/symptoms of abuse, neglect, misappropriation, and/or exploitation and report to the facility's abuse officer and medical provider; refer for psychiatric evaluation and follow-up if indicated; and refer for psychology evaluation and ongoing services if indicated. The 2/4/24 Quarterly Minimum Data Set (an assessment tool) documented the resident was cognitively intact. On 2/20/24 at 11:30 AM, Resident #151 was observed asking Staff #35 (Certified Nurse Aide) two times for ice. Each time Staff #35 responded please in an inappropriate tone before providing Resident #151 the requested ice. On 02/20/24 at 11:32 AM Staff #35 (Certified Nurse Aide) stated saying please is something you do when asking for something. When asked if Resident #151 must say please to get ice, Staff #35 stated no it is just something you are supposed to say. On 2/20/24 at 3:33 PM, Resident #151 stated Staff #35 always talked nasty to them. On 02/26/24 at 11:39 AM, Staff #18 (Licensed Practical Nurse) stated that a resident does not have to say please when making a request. Staff #18 stated Staff #35 could have addressed Resident #151 in a more appropriate tone. 10NYCRR 415.3(c)(1)(i)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure residents rights to a safe, comfortable, home-like environment for 1 of 4 residents (Resident #114) observed during dining. Specifically, Resident #114 was not provided an overbed table and was observed eating their lunch meal which was placed on a chair in their room. On another occasion, the resident was observed lying in bed and staff placed the resident's food tray on their bed by their feet. Findings include: Resident #114 was admitted to the facility with a diagnosis and conditions of but not limited to Encephalopathy, Dementia and Depression. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe cognitive impairment and required substantial/maximal assistance with eating. During an observation on 02/14/24 at 12:37 PM Resident #114 was eating their lunch meal from a tray that had been placed on a chair next to the bed. During an observation on 02/16/24 at 12:22 PM Resident #114 was in bed asleep, their lunch meal tray was left on the bed at the resident's feet. There was no bedside table to place the meal on in the room. During an interview on 02/16/24 at 2:30 PM Staff #30 (Certified Nurse Aide) stated the resident was sleeping and did not have an overbed table, so they put the tray on the resident's bed. During an interview on 02/16/24 at 12:37 PM Staff #25 (Licensed Practical Nurse) stated that some of the residents did not have overbed tables in their rooms and the facility was aware of this. Sometimes staff used a bedside table from another resident's room during meals for a resident that did not have one. 10 NYCRR 415.29(e)(1)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review conducted during the recertification and abbreviated surveys (NY00324940 and NY00295143) from 2/12/24 to 2/27/24, it was determined for 2 of 5 residents (Residents # 274 and 224) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation of the completion of a thorough investigation and timely resolution of the residents' reports of missing chains with pendants. The findings are: The facility Policy and Procedure titled Grievances reviewed 2/1/23 documented that the facility would assist residents, representatives, family members, or resident advocates in filing a grievance/concern form when concerns are expressed, and the facility will investigate and resolve resident grievances in a timely manner to ensure resident's safety and protection of residents' rights. 1. Resident #274 was admitted with diagnoses including Diabetes Mellitus and a mental disorder. The Concern/Grievance-Resident Notification Summary dated 4/15/2022 documented a missing gold chain with a cross pendant, staff was interviewed and did not recall seeing such a necklace for Resident #274. The annual Minimum Data Set (an assessment tool) dated 9/17/23 documented severely impaired cognition. When interviewed by phone on 2/14/24 at 3:25 PM, Resident #274's representative stated they were never reimbursed for the missing 14 carat gold chain with cross which was lost almost two years ago in April 2022. On 2/15/24 at 10:24 AM, on 2/16/24 at 9:25 AM, and on 02/16 PM at 1:08 PM documentation was requested from the Administrator regarding Resident #274's missing gold chain with cross. The Administrator was unable to provide documentation. On 02/16 PM at 1:08 PM, during an interview the Administrator stated that the facility had conducted a search for the gold chain and cross on 4/15/2022. The Administrator stated that a week later on 4/22/2022 they documented that a reimbursement request would be submitted for review, and they would continue the search. The facility Administrator stated they did not find the missing item, and they did not follow up with the resident's representative to offer any compensation for the missing gold chain and cross or resolve the concern. On 2/20/24 at 10:59 AM, during an interview the Director of Social Work stated they had discussed reimbursement with the Administrator but did not follow-up with the resident's representative because they forgot about the grievance. 2. Resident #224 was admitted with diagnoses of chronic obstructive pulmonary disease, major depressive disorder and hypertension. The Minimum Data Set (an assessment tool) dated 5/11/2022 documented the resident had moderate cognitive impairment. A general documentation note in the resident's record dated 3/15/22 documented the staff were made aware of a missing necklace and informed the Social Worker. On 2/22/24 at 12:18 PM during an interview, the Director of Social Work stated they remember the resident's family member coming to them and reporting a chain was brought to Resident #224 in March 2022 and they could not find it. The Director of Social Work explained that the family member needed to fill out a grievance. The Director of Social Work stated they did not assist the resident's family member with initiating a grievance and did not initiate an investigation, interview staff, or look into the missing chain. On 2/27/24 at 12:27 PM during an interview, the Administrator stated without a completed grievance form there was nothing they could do. 10NYCRR 415.3(c)(1)(i)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview during the recertification and abbreviated surveys (NY00330459) from 2/12/24 to 2/27/24, the facility did not ensure that all alleged violations involving abuse and neglect were reported and/or reported timely to The New York State Department of Health for 2 of 3 residents reviewed for abuse and/or misappropriation (Residents #129 and #156). Specifically, 1) the facility did notify the New York State Dept of Health when Resident #80 pushed Resident #129 to the floor resulting in Resident #129 hitting their head requiring medical evaluation; and (2) the facility did not notify the New York State Department of Health timely when Resident #156's wallet and cell phone were stolen. Findings include: 1) 1) Resident #129 admitted with diagnoses that included dementia, muscle weakness, and difficulty walking. The Annual Minimum Data Set (an assessment tool) dated 11/7/23 documented Resident #129's cognition was severely impaired and no documented behavioral symptoms. Resident #80 was admitted with diagnoses that included dementia with agitation, bipolar disorder, depression, anxiety, delusional disorder. The Annual Minimum Data Set (an assessment tool) dated 2/2/24 documented the Resident #80's cognition was severely impaired and no documented behavioral symptoms. The facility Accident/Incident investigation for Resident #129 dated 1/25/24 documented that a Certified Nurse Aide observed Resident #129 being pushed by their roommate Resident #80. Resident #129 was transferred to emergency room for evaluation, CT scan of head and X-Ray of hip, results were negative. It further documented the incident was investigated and concluded it was a behavior associated incident due to dementia, no injury, and was determined not reportable. The facility Accident/Incident Report was signed by the Director of Nursing on 2/20/24. The Resident-to-Resident Altercation Report for Resident #80 dated 1/25/24 documented Resident #80 was agitated telling their roommate (Resident #129) to move out of the way, pushed roommate's walker, causing Resident #129 to fall, and hit their head on the floor. Resident #80 was transferred to hospital for Psychiatry evaluation and returned to facility deemed as not dangerous to self or others. It further documented the incident behavior was associated with dementia and not reportable to DOH. The Report was signed by the Director of Nursing on 2/21/24. When interviewed on 2/26/24 at 2:50 PM, the Director of Nursing stated it was an isolated incident and felt it was dementia related and not reportable. 2) Resident #156 admitted [DATE] with diagnoses that included stroke, depression, and bipolar disorder. The Quarterly Minimal Data Set (MDS) dated [DATE] documented the resident's cognition was moderately impaired. The Grievance Report Summary, undated, documented on 11/27/23 Resident #156's family member asked the social worker to look for and retrieve the resident's wallet with debit/credit cards and a cell phone. The family member reported the debit card was being used by someone as per the resident's bank records. The family member was able to be present at facility on 12/1/23 and filed a police report. On 12/20/23 the Detective informed the Social Worker that they were able to identify the subject (housekeeper) as someone who worked at the facility. When interviewed on 2/23/24 at 12:08 PM, the Director of Social Work stated on 11/27/23 they looked for the belongings and on 12/1/23 a police report was made. They continued to investigate the case and on 12/20/23 the police showed up at the facility with a video and photo. The facility was able to identify the person. The Director of Social Work stated the Director of Nursing was responsible for reporting the incident to the New York State Department of Health. When interviewed on 2/23/24 at 1:04 PM, the Administrator and (Director of Nursing present) stated they began the investigation on 11/27/23 and they did not know enough to report. They stated when they have something conclusive is when they report to New York State Department of Health. They stated they reported it within 48 hours after receiving evidence from the police. 10NYCRR 415.4 (b)(2)(3)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, the facility did not notify the ombudsman for 1 of 2 residents (Resident # 105) reviewed for hospitalization. Specifically, the resident was transferred to the hospital and the facility could not provide evidence that notification was sent to the ombudsman. The findings are: Resident #105 was admitted with diagnoses which included Diabetes Mellitus, Alzheimer's Disease, Dementia. The discharge Minimum Data Set assessment dated [DATE] documented the resident had an unplanned discharge, return anticipated. On 2/23/24 at 4:20 PM during an interview with the Director of Social Work, they stated they were not responsible for notifying the ombudsman of resident's transfers. On 2/27/24 at 8:37 AM during an interview the Ombudsman stated they did not receive notification that Resident #105 was transferred to the hospital on [DATE]. On 2/27/24 at 1:16 PM during an interview with the Administrator, they stated the Director of Social Work was responsible for notifying the Ombudsman of resident transfers. 10 NYCRR 415.3 (i)(1)(ii)(a)(b)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on observations record review and interviews, during the recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for 1 of 4 residents reviewed for accidents. Specifically, Resident #129 was involeved in a resident-to-resident altercation on 1/25/24 and the Behavior and Abuse Care Plans were not revised and/or updated to reflect new interventions to prevent reoccurrences. The findings are: Resident #129 was admitted with diagnoses that included non-Alzheimer's dementia, muscle weakness, and difficulty walking. The Annual Minimum Data Set (an assessment tool) dated 11/7/23 documented Resident #129's cognition was severely impaired and the resident exhibited no documented behavioral symptoms. Facility Accident/Incident investigation for Resident #129 dated 1/25/24 documented that a Certified Nurse Aide observed Resident #129 being pushed to the floor by their roommate, Resident #80. Resident was transferred to emergency room for evaluation. There was no documented evidence that revisions to the abuse care plan or behavior care plan to reflect the incident that occurred on 1/25/24 had been included and there was no evidence of any new interventions to the care plan. On 2/27/24 at 10:30 Staff #24 (Registered Nurse Supervisor) stated they were at the 1/25/24 incident and was called to the unit by the Charge Nurse who stated Resident #80 pushed Resident #129 backwards and fell hitting their head. Stated there were no new interventions planned and they were unaware of care plans not being revised. On 2/26/24 at 2:50 PM, Director of Nursing stated was unaware that care plans were not revised to reflect incident on 1/25/24. 10 NYCRR 415.11(c)(1)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview during recertification and abbreviated surveys (NY00321475) from 2/12/24 to 2/27/24, the facility did not ensure a resident who was unable to carry out activities of daily living received services and assistance to maintain good personal hygiene for 1 out of 9 residents (Resident #234) reviewed for activities of daily living. Specifically, there was no documented evidence that colostomy care, bed baths, hoyer lift transfer and bladder incontinence care were consistently provided for Resident #234 as per physician order and/or the comprehensive care plan. Findings include: Resident #234 was admitted to the facility with diagnoses including intellectual disabilities, schizoaffective disorder and obstructive uropathy. The quarterly Minimum Data Set (an assessment tool) dated 7/3/2023, documented a Brief Interview for Mental Status score of 10 (moderate cognitive impairment), inattentive and disorganized thinking at times. The resident had a colostomy and was totally dependent for toileting, transfers and bathing. The care plan dated 12/7/2022, documented to maintain ostomy device and empty as needed, provide ostomy care every day every shift and as needed. Review of the facility's resident census list documented Resident #234 was hospitalized on [DATE] and returned to the facility on 6/15/2023. The physician's order dated 6/16/2023 documented colostomy care every shift and as needed; and to transfer the resident out of bed to the wheelchair via hoyer lift and 2-person assistance as tolerated. There was no documented evidence in the June 2023 Treatment Administration Record to indicate colostomy care was provided on 6/16/2023 at 7 AM. Review of the facility's resident census list documented Resident #234 was hospitalized on [DATE] and returned to the facility on 6/26/2023. Physician order dated 6/29/2023 documented colostomy care every shift and as needed. Further review of the resident's record revealed no documented colostomy care from 6/26/2023-6/29/2023. The Certified Nurse Aide [NAME] (care instructions) dated June, July, and August 2023, documented the resident was to receive a bed bath, be transferred out of bed and receive bladder/incontinence care every day every shift. There was no documented evidence to indicate the resident received a bed bath on 7 occasions in June, 9 occasions in July, and 5 occasions in August. There was no documentation the resident was transferred out of bed on 8 occasions in June, 8 in July, and 9 in August. There was no documentation the resident received bladder incontinence care on 6 occasions in June, 9 in July, and 9 in August. There was no documented evidence in the August 2023 Treatment Administration Record that colostomy care was provided at night on 8/26/2023 and 8/27/2023. During an interview on 02/27/24 at 12:24 PM Staff #5 (Registered Nurse Unit Manager) stated an empty box with no code, meant it was not signed for or not done. They stated that it should have been documented if the resident refused or if it was held. 10 NYCRR 415.12(a)(3)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interviews conducted during the Recertification and Abbreviated surveys (NY00320687) from 2/12/24 to 2/27/24, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #64) reviewed for antibiotic use. Specifically, Resident #64 did not receive intravenous antibiotic medication Meropenem as ordered by the medical provider at 12 AM, 6 AM, 12 PM and 6 PM on 7/22/2023 and the medical provider was not notified. Findings include: Policy and Procedure Admission, readmission revised 9/2022 documented it is the philosophy of the Facility to admit residents 24 hours per day, 7 days a week, based upon a clinical decision that considers the resident's needs, the Facility's ability to meet those needs. Policy and Procedure medication Administration revised 12/2019 documented medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. Resident #64 was re-admitted from the hospital with diagnoses including urinary tract infection, gastrointestinal bleed, and anemia. The hospital discharge instructions documented the resident had a diagnosis of extended spectrum beta lactamases in the urine. The hospital discharge instructions documented to start intravenous Meropenem 500 mg every 6 hours for 7 doses. The annual Minimum Data Set (an assessment tool) dated 7/8/2023 documented intact cognition. The Physician's order dated 7/21/23 documented Meropenem Sodium Chloride intravenous solution 500 mg/50 ml, 7 doses intravenously every 6 hours for urinary tract infection at 12 AM, 6 AM, 12 PM, and 6 PM. Nurse's notes dated 7/22/23 at 14:17 and at 20:56 documented they could not start an intravenous line for the resident. There was no documented evidence in the resident's medical record that the physician or nurse practitioner were made aware that the Meropenem was not administered. The Medication Administration Record dated 7/22/23 did not document that Meropenem was administered at 12 AM or 6 AM or 12 PM or 6 PM. On 2/23/24 at 10:57 AM, during an interview with Staff #5 (Registered Nurse Unit Manager), they stated they could not locate any notes which documented that the Physician or Nurse Practitioner were made aware that the resident's intravenous line could not be initiated and that the antibiotic Meropenem could not be administered. Staff #5 stated it was the nurse's responsibility to notify the Physician or Nurse Practitioner and document in the resident's medical record that the Physician was aware and to document any new orders. On 2/23/23 at 11:15 AM during an interview with Staff #6 (Registered Nurse Unit Manager), they stated they could not find any notes which documented that the Physician or Nurse Practitioner were made aware that the resident's intravenous line could not be started and that therefore the antibiotic Meropenem could not be administered. Staff #6 stated that if a medication cannot be administered for any reason, they should notify the Physician or Nurse Practitioner and document in the resident's medical record. On 2/23/23 at 11:40 AM during an interview with Staff #7 (Nurse Practitioner), they stated there was no documentation that the nurses were unable to start an intravenous line on the resident and therefore they could not administer the Meropenem. On 2/23/23 at 12:01 PM during an interview with Staff #8 (Registered Nurse Supervisor), they stated they should have notified the Physician or Nurse Practitioner that they were unable to start an intravenous line on the resident and therefore they could not administer the antibiotic Meropenem. On 2/23/23 at 12:30 PM during an interview with the Medical Director, they stated that if they had been notified that the resident's intravenous line could not be started, and that the resident did not receive the antibiotic Meropenem, they would have ordered another medication. On 2/23/23 at 1:20 PM, during an interview with the Director of Nursing, they stated that if there is any issue regarding the administration of an ordered medication, the nurse must call the Physician or Nurse Practitioner by the time the medication is due. The Director of Nursing stated that a nurse must have a Physician's or Nurse Practitioner's order to hold a medication. 10NYCRR 415.12

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that each resident received adequate supervision and that the environment remained as free from accidents as possible for 1 out of 4 residents (Resident #114) observed during dining. Specifically, supervision during meal intake was not provided as per care plan and staff did not ensure the resindent remained upright for 30 minutes after meals as per speech pathologist recommendation for Resident #114 with aspiration precautions. Findings include: Resident #114 was admitted to the facility with a diagnoses including dysphagia, dementia and depression. The care plan dated 10/1/21, documented the resident had potential for aspiration related to dysphagia. Interventions included to encourage resident to be out of bed for meals, keep/maintain upright sitting position when assisting resident with meals and at least 30 min after meal. Resident must be supervised for all intake solid or liquid. The Speech Language Pathology referral progress note dated 12/8/23, documented the resident required assistance with set up of meal and assistance to utilize utensils appropriately. Resident was unable to cut up food independently. Recommend resident was put on an advanced mechanical soft diet consistency with thin liquids. Additionally, it is recommended that the resident is out of bed for all meals and remains upright for 30 minutes after eating. The physician's order dated 12/8/23 documented a diet order of no salt packet diet, advanced mechanical soft texture, thin (regular) consistency, for facilitating oral intake remain upright for 30 minutes after eating. The Quarterly Minimum Data Set (MDS) dated [DATE], documented the resident had severe cognitive impairment and required substantial/maximal assistance with eating. The dietary progress note date 12/11/23, documented resident needed extensive assistance during eating. The resident had a speech language pathology evaluation on 12/8/23, which documented, diet downgraded from regular texture due to mild, excessive/effortful mastication. Full diet order is now no salt packet, advanced mechanical soft, thin liquids, out of bed for all meals, remain upright for 30 minutes after meals, aspiration precautions, assistance with set up using utensils. Resident # 114 was observed on 02/12/24 at 12:18 PM eating lunch in the room without staff supervision Food received on the tray included chopped chicken tenders with gravy, mashed potatoes and a pureed fruit cup. Yellow mat noted on the bottom of the tray, indicating aspiration precautions. Resident #114 consumed some of the meal and then proceeded to lay back down in the bed. Resident #114 was observed on 02/14/24 at 12:37 PM sitting on the bed in their room eating lunch with their hands without staff supervision and/or assistance. The utensils remained wrapped on the side of the meal tray. During an interview on 02/20/24 at 03:34 PM Staff #25 (Licensed Practical Nurse) stated Resident #114 always ate in their room alone, after set up assist from the certified nurse aide. They stated sometimes the resident did not want to eat in the dining room. The staff try to encourage them to come to the dining room, but sometimes they refused. During an interview on 02/20/24 at 03:37 PM Staff #5 (Registered Nurse Unit Manager) stated Resident #114 needed assistance with meals, they were capable, but they did not follow the instructions as provided. The stated the resident was not on aspiration precautions, howerver upon review of the record with the surveyor, they stated they were on aspiration precautions and required extensive assistance with meals. 10 NYCRR 415.12 (h)(2)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey conducted 2/12/24 to 2/27/24, the facility did not ensure each resident was offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 2 of 5 residents (Resident #165, #168) reviewed for infection control. Specifically, there was no documented evidence Resident #165, #168 was offered, declined, and/or were educated about the COVID-19 vaccination. Findings include: The facility policy titled COVID Vaccine: Residents and Healthcare Personnel, dated 12/4/23, documented upon admission/readmission, the facility shall obtain COVID 19 vaccine history to all extent possible and COVID 19 vaccine will be offered, promoted and encouraged to eligible residents and Healthcare Personnel. Prior to offering the vaccine Healthcare Personnel, residents or their representatives should be provided education regarding the vaccine. The Healthcare Personnel, residents, or their representative is provided a copy of the Vaccine Information sheet (VIS) before being offered the vaccine. Healthcare personnel, residents and their representatives may except or decline the vaccine after education is provided. The facility shall maintain documentation of Healthcare Personnel and residents' education, decision, and vaccination administration for COVID 19 vaccines. Resident #165 was admitted with diagnoses including history of COVID-19 and dementia. The 1/3/24 admission Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment. There was no documented evidence that Resident #165 was offered, received, declined, or was provided with education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccination. Resident #168 was admitted with diagnoses of type II diabetes Mellitus, hypertension, and subdural hematoma. The admission Minimum Data Set (MDS) dated [DATE] documented the resident had severe cognitive impairment. There was no documented evidence in the immunization record that Resident #168 was offered, educated or declined COVID vaccine. During an interview with the Assistant Director of Nursing on 2/16/24 at 1:07 PM they stated they were responsible for the vaccine program but only dealt with the influenza vaccine and stated the Director of Nursing dealt with the COVID vaccine. They stated they remember there was a conversation with the family regarding Resident #165's vaccine but there was no documentation. During an interview with the Director of Nursing 2/16/24 at 2:36 PM they stated they dealt with the COVID vaccine for residents and Staff. They stated they did not have a list or spreadsheet of resident's vaccine status but stated if the resident requested it, they would give the resident the vaccine. The Director of Nursing stated there was no visible signage anywhere in the building promoting the COVID 19 vaccine. 10NYCRR 415.19 (a)(1-3)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

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Based on observation, record review and interviews conducted during the recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID). This was evident for 5 of 35 residents reviewed. Specially, Residents #34, #151, #105, #79, and #117 did not have the required pre-admission screening and resident review assessment completed prior to their admission to the facility. The findings are: The facility policy and procedure entitled PASARR/Screens last revised 12/2019 documented that prior to every resident's admission to the facility, they would have completed a level 1 pre-admission screening and resident review screen to ensure the residents are appropriate for the facility. In addition, residents that are identified with serious mental illness or intellectual disability would have a completed level 2 pre-admission screening and resident review screen. The facility will protect the rights of the residents with mental illness and/or intellectual disabilities by ensuring the delivery of mental health services as needed. 1.Resident # 34 was admitted to the facility with diagnoses including dementia, depression and peripheral vascular disease. The quarterly Minimum Data Set (a resident assessment tool) dated 12/21/23 revealed resident cognition as moderately impaired. The resident electronic medical record revealed there was no documented evidence of a pre-admission screening and resident review (PASRR) assessment completed prior to admission to the facility. 2. Resident # 151 was admitted to the facility with diagnoses including dementia, pulmonary hypertension, and seizure disorder. The quarterly Minimum Data Set (a resident assessment tool) dated 2/14/24 revealed resident cognition as mildly impaired. The resident electronic medical record revealed no documented evidence of a pre-admission screening and resident review assessment completed prior to admission to the facility. 3. Resident #105 was admitted to the facility with diagnoses which included diabetes mellitus, alzheimer's disease, and dementia. The admission Minimum Data Set (a resident assessment tool) dated 7/27/23 documented severely impaired cognition. The resident's electronic medical record revealed there was no documented evidence of a pre-admission screening and resident review screen completed. On 2/16/24 at 2:00 PM the Director of Social Work brought in a folder containing pre-admission screening and resident review (PASRR) screens for some requested residents and documentation on the outside of the folder that five (5) residents did not have pre-admission screening and resident review screens in their medical records. On 2/20/24 at 10:55 AM, during an interview with the Director of Social Work, they stated the pre-admission screening and resident review screen for Residents #34, #151, #105, #79, and #117 could not be located in their hard charts or in their electronic medical records. The Director of Social Work stated the Admissions Director was responsible to make sure all residents being admitted to the facility had a pre-admission screening and resident review in the medical record at the facility prior to admission. The Director of Social stated they were responsible for checking that all newly admitted residents had a pre-admission screening and resident review in the medical record at the facility. The Director of Social Work stated that if a resident did not have a pre-admission screening and resident review on file, they were responsible to screen the resident to assure appropriate placement. On 2/20/24 at 11:40 AM, during an interview with Staff #1 (Admissions Coordinator/Unit Clerk/Transportation Coordinator), they stated that when a resident was being admitted to the facility from the hospital, they received all the required documents for admission from Corporate Admission. Staff #1 stated that if a document was missing when they reviewed the required documents prior to admission, they emailed Corporate Admissions, to let them know, and they verbally notified the facility Director of Social Work if a pre-admission screening and resident review screen was missing. Staff #1 stated that the Director of Social Work was responsible to follow-up regarding any missing pre-admission screening and resident reviewonce a resident had been admitted to the facility. Staff #1 stated they deleted their old emails and did not have documentation of having sent an email to Corporate Admissions. NYCRR 415.11 (e)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on record reviews and interviews during the Recertification Survey from 2/12/24 to 2/27/24, the facility did not ensure that Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, performance evaluations were not conducted every 12 months for 9 of 10 Certified Nurse Aides (Staff #13, 14, 15,16,16, 38, 39, 40, and 41) records reviewed. The findings are: Facility documentation revealed the most recent performance evaluation for: - Staff #13 was dated 10/12/15. - Staff #14 was dated 1/14/15. - Staff #15 was dated 1/14/15. - Staff #16 was dated 10/12/15. - Staff #17 was dated 2/22/18. There was no documented evidence of any performance evaluations for Staff #38, 39, 40, and 41. On 2/15/2024 at 3:45 PM, the Human Resources Director stated they could not locate any current performance evaluations, and that perhaps the Certified Nurse Aide performance evaluations were located in the Director of Nursing office. On 2/15/2024 at 3:56 PM, the Director of Nursing stated they did the performance reviews annually in February. The Director of Nursing stated they did the last reviews in February 2023 and they were kept in the Human Resources office. On 2/15/2024 at 4:50 PM, the Director of Nursing stated they could not find the performance reviews for any of the requested certified nurse aides. 10 NYCRR 415.26

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review during a recertification survey from 2/12/24 to 2/27/24, the facility did not ensure that they store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were baking sheets on the floor in the kitchen, garbage was placed on top of a cart next to a pan storage rack with a whisk touching the garbage bags, thermometers used for food thermometers were not sanitized properly, sanitizer logs were not completed, a dining room resident refrigerator, freezer thermometer, was not working and resident's personal food items were not dated and labeled appropriately. Findings include: During a walk-through observation and interview with the Food Service Director on 02/12/24 at 09:56 AM, there were 4 baking pans on the floor in between equipment in the kitchen. The Food Service Director picked the baking pans up and stated they did not know why they were there. A cart with clear bags filled with garbage on top of it was observed in the middle of kitchen, near the red meat pans. A plastic barrier was hanging over the meat pan rack and was noted to be partially lifted. A whisk was seen on the rack protruding out, the whisk was touching some of the clear garbage bags. The Food Service Director put the barrier back in place, but the whisk was still touching the bags. The Food Service Director stated that the plastic barrier was to protect the clean pans from splashing by the sink water, no sinks were near the pan storage rack. During an inspection of the dairy freezer 02/15/24 at 03:13 PM, the ice cream was noted to not be frozen solid, the container was easily squeezed. There was a frozen pie dated, 10/9/23 and not sealed. There were a tray of croissants resting on a top rack covered with parchment paper, with an fan blowing over them lifting the parchment paper, exposing the rack to the environment. While observing the prep line food temperature measurements, Staff #37 (PM dietary cook) dipped the thermometer in the hot dishes, one after another without cleaning the thermometer in between. Staff #37 did not wear gloves when checking the temperatures. The Food Service Director was watching the procedure and handed them a alcohol swab, opened with no gloves on, to cleanse the thermometer after the temperatures were taken. Review of the sanitizer log revealed it was not completed 2/15/24 for the entire day. The Food Service Director stated the sanitizer levels were checked 3 times daily and stated they check the sanitizer in the morning, but it was a busy day today. During an observation on 02/16/24 at 11:47 AM the 3rd floor dining room refrigerator had a freezer thermometer temperature read of -20 degrees. There were residents items in it the freezer with names on them and no date. In the refrigerator, there was a large shopping bag with cold cut items and mayonnaise in it, not dated. There was also a large shopping bag with 5 plastic containers (of rice, bean and miscellaneous items) and tortillas in it, not labeled with a name or date. During an interview Staff#26 (Licensed Practical Nurse) stated the thermometer was working this morning. Stated they will tell maintenance and the nursing supervisor it needed to be changed. Staff #26 removed the shopping bags of the resident's food items, from the refrigerator, and stated will ask them what date they received it. During an observation on 02/16/24 at 11:40 AM the 4th floor dining room refrigerator temperature log was not completed for 2/15/24 evening and night shift. Staff# 27 (Registered Nurse unit manager-4th floor), completed the temperature log for 2/16/24 7 am -3 pm shift, while checking the fridge. 10 NYCRR 415.14(h)

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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Based on record review and interview during the recertification survey 2/12/24 to 2/27/24, the facility did not ensure each resident was offered influenza and/or pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 4 (Residents #63, #96, #165 and #168) of 5 residents reviewed. Specifically, the facility did not ensure, Resident #63 was screened properly for influenza immunization, and/or Residents #96, #165, and #168 were screened for eligibility, offered and educated about pneumococcal immunizations. This was evidenced by: The facility policy titled Resident Immunizations dated 9/1/23 documented the facility will offer immunizations to residents who consent to aid in the prevention of infectious diseases/conditions in accordance with the Centers for Disease Control and Prevention (CDC) and the Advisory Committee for Immunization Practices. The facility policy for Pneumococcal Vaccination dated 5/23/23 documented prior to or within 5 working days after admission residents will be assessed for eligibility to receive pneumococcal vaccine and when indicated will be offered and provided the vaccine within 30 days of admission unless medically indicated or the resident is not eligible to receive. Residents who are eligible for pneumococcal vaccination will be offered the vaccine and provided with the current copy of the Vaccine Information Sheet for the pneumococcal conjugate vaccine. There was no documented evidence in Resident #63's immunization record of an influenza immunization for the current influenza season. A consent form dated 9/7/23, with a hand written note documented received 4/23/23, not eligible. On 2/16/24 at 11:10 AM the Assistant Director of Nursing/Infection Preventionist stated they screened the resident for influenza immunization on 9/7/23 and was confused by the season and thought 4/23/23 influenza vaccine was good but now realized the resident should have received the vaccine on 9/7/23 and the 4/23/23 vaccine was from last season There was no documented evidence in Resident # 96's immunization record that the facility screened the resident for eligibility, administered the the vaccine or provided education about the vaccine to the resident or the resident's representative. There was no documented evidence in Resident # 165's immunization record that the facility screened the resident for eligibility, administered the the vaccine or provided education about the vaccine to the resident or the resident's representative. There was no documented evidence in Resident # 168's immunization record that the facility screened the resident for eligibility, administered the the vaccine or provided education about the vaccine to the resident or the resident's representative. On 2/16/24 at 11:10 AM the Assistant Director of Nursing/ Infection Preventionist stated they were responsible for the facility immunization program but only dealt with the flu shot for residents. The Assistant Director of Nursing stated they were not aware residents needed to be assessed for eligibility or provided with proof of education. The Assistant Director of Nursing 2/16/24 stated they had not been screening or offering pneumococcal vaccines to residents because they did not know they had to give the pneumococcal vaccine. 10NYCRR 415.19 (a)(3)

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review conducted during the recertification and abbreviated surveys (NY00328066) from 2/12/24 to 2/27/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during confidential interviews and the group meeting that the facility was short staffed at times especially at night and on the weekends, there was a lack of timely staff response to call bells, and some stated that they smelled urine odors, 2) multiple nursing staff members reported a lack of sufficient staffing; and 3) analysis of the actual staffing schedule showed that on multiple occasions from January 13, 2024 through February 15, 2024, the facility was below the minimum levels documented on the Facility Assessment. Findings include: On 2/12/24 at 10:36 AM, Resident #92 stated they got a shower today after a month, and that the facility needed more help/needed to hire people. On 2/12/2024 at 10:21 AM, Resident #475 stated they have waited too long to be changed. and that when the call bell goes off only the assigned staff would answer the call bell. On 2/12/24 at 11:22 AM, Resident #47 was observed incontinent, lying in bed with urine on their pants. Resident #47 stated they asked for a spoon earlier that day and never got one. During a Resident Council meeting on 2/14/24 at 11:07 AM several residents stated that the facility was short staffed at times, especially at night or on weekends. Residents stated that the call lights could ring for a while before someone answered them and some stated that they have smelled a urine odor. On 2/14/24 at 12:01 PM, during a follow up interview Resident #47 stated staff took a long time to come when they rang their call bell and at times staff did not respond at all. On 2/14/24 at 11:35 AM, Resident #23 stated staffing was not adequate. Stated they rang their call bell and waited a long time. Stated the call bells were useless because no one responded to the bell The staffing sheets from January 13 2024 through February 15 2024, and the Facility Assessment for resident to staff ratios, revealed the 7 AM-3 PM shift was understaffed 34 of 34 days; the 3 PM-11 PM shift was understaffed 34 of 34 evenings; and the 11 PM-7 AM shift was understaffed 34 of 34 nights. On 2/20/24 at 12:15 PM during an interview, Staff #3, (Certified Nurse Aide) stated at times they had to work with 3 certified nurse aides which meant each of the certified nurse aides were responsible for the care of 13 to 14 residents and stated that resident care was affected by this. On 2/20/24 at 12:47 PM during an interview, Staff #2, (Licensed Practical Nurse) stated at times they had worked with only 2 or 3 certified nurse aides. They stated with only 2 certified nurse aides, each certified nurse aide was responsible for the care of 20 residents and stated that resident care was negatively affected by this. They stated that the evening and night shifts were often short staffed. They stated the certified nurse aides were often asked to stay to work a double shift. On 2/20/24 at 1:03 PM during an interview, Staff #4, (Certified Nurse Aide) stated at times they had to work with only 3 or 4 certified nurse aides. They stated with only 3 or 4 certified nurse aides, the resident care was negatively affected. They stated that many of the 3rd floor residents were dependent on staff for activities of daily living, and some had behavioral symptoms. They stated the certified nurse aides were often asked to work a double shift. 10NYCRR 415.13 (A)(1)(i-iii)

Apr 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an abbreviated survey (NY00301588) it could not be ensured that for 1 (Resident #1) of 3 residents reviewed for Resident Rights, that the right to self-determination through support of resident choice about aspects of their life in the facility that are significant to the resident was timely met by the facility. Specifically, Resident #1 request for extra linens, sheets, blankets, and/or towels was not honored in a timely manner. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation (AF), Disruption of External operation (surgical) wound, Morbid obesity, and Hereditary and Idiopathic Neuropathy. The modified annual MDS (Minimum Data Set, an assessment tool) dated 1/2/2023 documented Resident's Brief Interview for Mental Status (BIMS) score of 15 indicated intact cognition for decision making. A Policy and Procedure dated 10/2016, last date revised 12/2019 and titled Resident Counsel revealed Council meetings will be held monthly, a designated staff representative will facilitate the meetings, minutes from the previous meeting will be reviewed, concerns reported at the meeting will be recorded in minutes and followed with a concern/response form filled out by the designated staff representative and addressed to the corresponding Department Head to provide a resolution. All supporting documentation .must be attached .a concern that may need to be investigated must be escalated to Social Services as a grievance. Resident who expressed a concern will be provided with a resident notification summary of the concern stated, resolution given by the Departments heads, and will be asked to sign a notification summary if resident acknowledges and agrees with resolution. A Policy and Procedure dated 3/2016, revised 2/1/2023, and titled Grievances documented that the facility assists residents in filing a grievance/concern form when concerns are expressed. The facility investigates and resolves resident grievances in a timely manner to ensure resident's safety and protection of residents' rights. Procedures included but were not limited to grievances/complaints may be submitted orally, in writing, or anonymously and the Grievance Officer coordinates adequately, and timely handling of grievances/complaints and resolutions are maintained and reviewed with administration routinely. Resident Counsel minutes for 3/2/2022-12/7/2023 were reviewed and revealed: Meeting minutes dated 7/8/2022 documented Resident #1 wanted more linens, sheets, and blankets, and sometimes his bed was not made until 9:00 PM. A Resident Council concern/response form dated 7/8/22 was sent to the designated department responsible (Housekeeping), and the documented response was that enough linens had been delivered to all floors, and Impossible Resident bed had been made around 9 pm. Carts (linen) had been stocked as per our par level. The Response was signed by the Housekeeping Director, undated, and there was no documented evidence that the response had been discussed with or had been signed off on by Resident #1. Meeting minutes dated 8/3/2022 documented Resident #1 reported wanting more soap in his bathroom, and more sheets and towels. A Resident Council concern/response form dated 8/3/2022 was sent to Housekeeping and the documented response was soap was placed inside room and Towels, sheets, gowns had all been opened and had been placed into circulation. The Response had been signed by the Housekeeping Director, was undated, and there was no documented evidence that the response had been discussed with or had been signed off on by Resident #1. Meeting minutes dated 9/7/2022 documented that Resident #1 reported not having enough towels and sheets, and the Housekeeping Director was present and indicated that more had just come in. The Administrator was present and indicated that residents should be refraining from keeping sheets and towels stored in their rooms. There was no documented evidence that a Resident Council-Concern/Response Form was generated for Resident #1's concern, or that Resident #1 had signed off on the response given in the meeting. Meeting minutes dated 12/7/2022 documented that Resident #1 reported they needed extra towels and sheets, and this would be discussed with the Housekeeping Director. There was no documented evidence that a Resident Council -Concern/Response Form was generated for Resident #1's concern or that any action had been taken to address it. A Grievance Form completed by the Social Worker (MSW) on 1/26/2023 documented that Resident #1 reported an ongoing issue with a shortage of linens and towels since approximately April of 2022, their concerns were brought up on multiple occasions during Resident Counsel, but the issue remained. The Grievance investigation revealed that on 2/6/2023 the Housekeeping Director and MSW met with Resident #1, a plan of action was put in place, and the issue was resolved. An interview conducted with the Administrator on 2/23/2023 at 9:15 revealed Resident #1 had asked for more towels a while ago, but he was not aware how long the resident was asking or how long it took to resolve the issue. The Social Worker (MSW) was interviewed on 2/23/23 at 2:51 PM and revealed the resident attended the resident council meeting in January 2023, reported not getting enough towels, and the MSW met with them privately to complete a grievance. The MSW referred the grievance to Administration and the Housekeeping Director and also made the Director of Nursing (DON) aware. A plan was put into place and no further complaint were voiced by the resident. An interview conducted with Resident #1 on 2/23/23 at 3:41 pm, revealed in the past there was not enough towels and sheets and he would bring it up in Resident Counsel but it took a long time to get more. An interview conducted with the Director of Recreation on 3/17/2023 at 8:46 am revealed she scheduled a monthly Resident Counsel meeting, recorded the minutes of the meeting, and filled in 2 forms. The first form was titled Resident Counsel Concern/Response Form on which a description of the concern would be documented. The form would then be given to the appropriate department to investigate, a response indicating the action taken would be documented, and the responsible department would sign off on it. The Director of Recreation further reported that starting in October 2022, a 2nd form titled Resident Satisfaction Survey/Resident Notification Summary had been implemented and the department responsible for the concern would have been responsible to complete the actions that had been taken to address the concern, then the completed form #2 would have been reviewed with the affected Resident and would have been signed off on by the Resident. A follow up telephone interview conducted with the MSW on 4/4/2023 at 12:41PM revealed she became aware of Resident #1's issue with linens about November or December 2022. The MSW stated the issue should not have gone on so long. The MSW reported that for Grievances social work was responsible for following up with the Resident to sign off on the resolution. For concerns reported at Resident Counsel, the Director of Recreation was responsible for follow up. 483.10(f)(2)

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interviews and record review conducted during an abbreviated survey (NY00301588) it could not be ensured for 1 (Resident #1) of 3 residents reviewed for treatments that the facility provided the necessary care and treatment in accordance with professional standards of practice. Specifically, wound treatments were omitted on multiple days. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation (AF), Disruption of External operation (surgical) wound, Morbid obesity, and Hereditary and Idiopathic Neuropathy. The modified annual MDS (Minimum Data Set, an assessment tool) dated 1/2/2023 documented Resident #1's Brief Interview for Mental Status (BIMS) score of 15, indicated intact cognition for decision making. The MDS also documented Resident #1 had a surgical wound and wound care treatment. The Care Plan, dated 2/16/2022, documented an alteration in skin integrity related to status post-surgical wound posterior neck. Interventions include weekly wound assessments, monitoring dressing daily, ,monitoring wound daily for signs/symptoms of infection, referring to wound care specialist as needed, and dietitian for nutritional evaluation. A Policy and Procedure dated 2/2020, last revised 2/2022, and titled Omissions in Medication Administration Records and/or Treatment Administration Records revealed the Licensed Nurse (LPN/RN) must ensure prior to the end of their shift all treatment administered/refused/held, etc. are properly documented on the Treatment Administration Record (TAR). The physician order dated 10/10/2022, documented Tegaderm contact Layer Pad 8, apply to skin topically 2x/day for wound care dressing cover neck with xeroform, gauze, and secure with Tegaderm. Review of the January 2023 TAR revealed no documentation that Resident #1's Tegaderm contact Layer Pad 8 was applied on at 9 am 1/11/23 and 5 pm 1/13/23. A wound care clinic note dated 11/14/2022 revealed Resident #1 had a follow up evaluation. The plan was to dress the wound with Aquacel AG, gauze, and Tegaderm; and continue local wound care changing daily. The physician order dated 11/14/22, documented Aquacel AG Advantage External Pad 4, apply to neck topically two times a day for wound care. Review of the January 2023 TAR revealed no documentation that Resident #1's Aquacel AG treatment was applied on 1/11/2023 at 9 am and on 1/13/2023 at 5 pm. The physician order dated 11/14/22, documented Calcium Alginate- Silver External Pad 2, apply to posterior neck topically every day and evening shift for post-surgical wound. Cleanse back of neck with normal saline pat dry apply Calcium Alginate with silver and cover with Tegaderm twice daily. Review of the January 2023 TAR revealed no documentation that Resident #1's Calcium Alginate- Silver treatment was applied on 1/11/23 at 7 am and on 1/13/23 at 3pm. The physician order dated 1/24/2023, documented Iodoform Packing strips, apply to posterior neck topically 2x/day for post-surgical wound post clean with normal saline pat dry, pack sinus then cover with DPD (Dry protective dressing). Review of the January 2023 TAR revealed no documentation that Resident #1's Iodoform Packing strips were applied on 1/27/23 at 5 PM, 2/4/23 at 9 am and 5 pm, and on 2/5/23 at 5 pm. A spinal wound consultation conducted on 2/16/2023 revealed Resident #1 was seen for the spinal track wound and the recommendation was good wound care with gauze and Allevyn dressing. The physician order dated 2/16/2023, documented Allevyn Thin pad 4 x 4 apply to neck topically two times a day for wound cover affected area with gauze and border dressing. Review of the February 2023 TAR revealed no documentation that Resident #1's Allevyn Thin pad 4 x 4 was applied on 2/21/23 at 9 am. Resident #1 was interviewed on 2/23/23 at 3:41 pm and reported that their neck wound was not being cared for properly, their wound dressings were supposed to be changed twice a day and it was not done as ordered. When interviewed on 3/8/2023 at 3:07PM, the Director of Nursing (DON) stated she was not aware of the treatment omissions for Resident #1. The DON stated nurses were responsible to ensure treatments were administered and documented on the TAR. When interviewed on 3/9/2023 at 4:26 PM, RN #3 stated Resident #1 directed their own care and sometimes declined treatments. The resident would be reapproached a few times across the shift, and the resident decided when/if the treatment was done. RN #3 thought she was in facility for 5 pm treatments on 1/11/23 and 1/13/23 and may have forgotten to document the refusal. When interviewed by phone on 3/16/2023 at 4:32 pm, LPN #1 stated when they offered the treatment to Resident #1, the resident was not ready, and the resident requested the dressing to be done at another time. LPN #1 stated the dressing always did get done and they did not know why the treatments were not signed for. LPN #1 also stated that when working the floor alone and caring for 40 residents they might have forgotten to sign for the treatment. § 483.25

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

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Based upon interviews and record review conducted during an abbreviated survey (NY00301588), the facility did not ensure that sufficient staffing was available to meet the needs of the 3rd floor residents. The findings are: Review of the facility assessment staffing par levels for the 3rd floor unit identified minimum staffing requirements of: Day shift: 5 Certified Nurse Aides (CNA), 3 Licensed Practical Nurses (LPN), 1 Registered Nurse (RN) Evening Shift: 4 CNA's, 2 LPN's, 1 RN Night shift: 2 CNA's, 1 LPN, 1 RN A Facility Policy and Procedure dated 4/2019, 3/2022 and titled Staffing Hours documented the facility provides adequate staffing on each shift to meet needed care and services for our resident population. The facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor delivery of services. Certified Nursing assistants are available on each shift to provide needed care and services of each resident as outlined on the resident's comprehensive care plan. The Staffing schedule dated Saturday January 7, 2023, through Tuesday February 7,2023 was reviewed and evaluated according to the facility assessment for the 3rd Floor Unit. In summary, of 96 shifts over 31 days, 61 shifts were short staffed for CNAs. Staffing Records Review: 1/7/23: Saturday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's - short 1 CNA. 1/8/23: Sunday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's - short 1 CNA. 1/9/23: Monday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's - short 1 CNA. 1/10/23: Tuesday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/11/23: Wednesday Evening shift scheduled 3 CNA's -short 1 CNA. 1/12/23: Thursday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/13/23: Friday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/14/23: Saturday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/15/23: Sunday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/16/23: Monday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. Night shift scheduled 1 CNA, short 1 CNA. 1/17/23: Tuesday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/18/23: Wednesday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/19/23: Thursday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/20/23: Friday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/21/23: Saturday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/22/23: Sunday Day shift scheduled 4 CNA's - short 1 CNA Evening shift scheduled 3 CNA's - short 1 CNA 1/23/23: Monday Day shift scheduled 3 CNA's - short 2 CNAs Evening shift scheduled 3 CNAs - short 1 CNA 1/24/23: Tuesday Day shift scheduled CNA's - short 1 CNA Evening scheduled 3 CNAs - short 1 CNA. 1/25/23: Wednesday Evening Shift scheduled 3 CNAs, short 1 CNA. 1/26/23: Thursday Day shift scheduled 4 CNAs, short 1 CNA. Evening shift scheduled 3 CNAs - short 1 CNA. 1/27/23: Friday Day shift scheduled 4 CNAs - short 1 CNA. Evening shift scheduled 3 CNAs - short 1 CNA. 1/28/23: Saturday Day shift scheduled 4 CNAs- short 1 CNA, Evening shift scheduled 3 CNAs - short 1 CAN. 1/29/23: Sunday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 1/30/23: Monday Evening shift scheduled 3 CNA's -short 1 CNA. 1/31/23: Tuesday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 2/1/23: Wednesday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 2/2/23: Thursday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 2/3/23: Friday Day shift scheduled 4 CNA's - 1 called sick - short 2 CNA's. Evening shift scheduled 3 CNA's -short 1 CNA. 2/4/23 Saturday Day shift scheduled 4 CNA's - short 1 CNA. 2/5/23: Sunday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 2/6/23: Monday Day shift scheduled 4 CNA's - short 1 CNA. Evening shift scheduled 3 CNA's -short 1 CNA. 2/7/23: Tuesday Evening shift scheduled 3 CNA's - short 1 CNA. Review of Resident Council Meeting Minutes for 3/2022 - 12/2022 revealed: -On 4/6/2022 the Director of Nursing (DON) mentioned we are going through a nursing shortage -On 5/4/2022 A resident mentioned that her floor was short staffed on Saturdays and Sundays, and DON discussed how we are working on hiring more nursing staff . -On 9/7/2022 a Resident mentioned a nurse shortage, and DON stated, we are still working on it . -On 11/2/2022 DON discussed our nursing shortage, and that we are working on staffing and to recruit, especially on weekends. -On 12/7/2022 DON let us know that staffing has improved. She asked that we work with her, be patient, and that the nurses are doing their best. An interview conducted with Registered Nurse #1 (RN #1) on 2/23/23 at 12:57 PM revealed that on the 7 am-3pm shift Resident #1 verbalizes concerns about staff. They are very independent but if they need a hand there are staff to help them. RN #1 reported that staff on 7 AM-3PM are usually 2 nurses on 7-3 and 4 CNA's, the work gets done, staff help each other, but she felt they could use more staff. In an interview conducted on 2/23/23 at 3:41PM Resident #1 reported their concern that the Nursing Home was short staffed, and sometimes on the weekends there was only one nurse for the whole (3rd) floor and two aides. The DON was interviewed by phone on 3/8/23 at 3:46 PM and reported that when the facility was short staffed, they call staff for overtime, reach out to supervisors and nurse managers, they do not have specific number of RN's scheduled each day, an RN may be utilized in place of an LPN, and the facility does not use an outside agency. The Nursing Scheduler was interviewed via telephone on 3/9/2023 at 2:30 pm and revealed she had been on leave from the facility for the past six weeks, the facility had not been having issues with staffing for morning or evening, if facility was short staffed the unit managers, DON, Assistant DON, and Supervisor's help, and an RN will be scheduled for an LPN's slot if needed. An interview conducted with the Administrator on 3/10/2023 at 9:30 am revealed: 1 RN was on at each shift, and other RNs are on site including the DON, ADON, 2 MDS RN's Monday-Friday, Evening and Night RN supervisors, and weekend RN supervisors each shift. The Administrator further reported that they staff to census. 415.13(a)(1)(i-iii)

Oct 2020 5 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification and an abbreviated survey (NY00259391) conducted from 10/19/2020 through 10/26/2020 it could not be ensured that the facility reported timely or thoroughly investigated all alleged violations involving abuse, neglect or mistreatment for 1 of 2 residents (Resident #118) reviewed. Specifically, Resident #118 sustained a laceration on his right hand after an interaction with a staff member. Supporting evidence to rule out abuse/neglect or evidence confirming that the incident was reported timely to the New York State Department of Health (NYSDOH) was not available for review despite several requests. The findings are: Resident #118 was admitted to the facility on [DATE] with diagnoses including Alcohol Dependence with Withdrawal, Cellulitis of Limb, and Major Depressive Disorder. According to the 6/25/2020 Annual Minimum Data Set (MDS; an assessment tool), the resident had a Brief Interview Mental Status (BIMS) score of 15/15 indicating cognition was intact for daily decision making. It further documented that Resident #118 displays verbal aggression directed towards others, rejects care 4-6 times per week and requires set up and supervision for all Activities of Living (ADLs). On 6/04/2020 Resident #118 reported to the NYSDOH Complaint Hotline that a woman who works in the Physical Therapy (PT) department is harassing him. Resident #118 explained when going downstairs to use the microwave to heat his coffee, a woman from the PT department yells and screams at him for using the microwave. He reported that last month (May 2020), she held a set of double doors closed where the microwave was so he could not get out. He reported that he has spoken with the facility Administrator as well as the Nursing Director about his concerns. Review of the facility policy for Abuse Investigations documented that the Administrator and the Director of Nursing (DON) are responsible for investigations. The policy notes that investigations should be thorough, with witness statements from anyone who may be interviewable and have detailed information regarding the allegation. During an interview on 10/22/2020 at 12:47pm, the DON stated that she remembered the incident when Resident #118 was physically and verbally abusive towards kitchen and PT staff. She stated she did not know why it was not in the binder of incidents presented for surveyors because she did an investigation and would look for it. On 10/26/2020 at 9:15am, Resident #118 was observed in bed, alert, oriented, talkative and friendly. He appeared unkempt hair messy, food on gown, and unshaven. Resident #118 showed the surveyor a 1.5 cm healed area on his right hand above the thumb. He stated that the healed area was a cut sustained maybe sometime in early June 2020 or before when he punched out a window in the PT door. Resident #118 was further interviewed on 10/26/2020 at 9:55am. He stated that he has reported the incident to the Administrator, Supervisor, DON, Ombudsman, and the NYSDOH Hotline. Stated, I now feel like she sneers at me as if saying I hit you with a door, spilled coffee all over you and you can't do anything about it. Resident continued explaining that the PT turned and went to her room after locking him out. He followed her because there is a microwave in the PT room, but she slammed the door, and my coffee spilled all over him. He explained that he got so mad that he punched the door window and smashed it, sustaining a n injury just above the right thumb which bled a lot because of blood thinners. Resident stated there was another person with the PT but does not remember who it was. Resident #118 went upstairs because of the bleeding hand and reported the incident to the Supervisor and Administrator. Resident #118 further explained that, the Administrator and Supervisor both said I'm not supposed to be there and that was the end of that. Resident #118 stated that he had been told a few times to not to go to the PT room for the microwave. RN #1 (Registered Nurse Manager) interviewed at 10:10am who stated that she remembers an incident with the Director of Rehabilitation in which Resident #118 went to the kitchen for coffee. The incident was discussed with the resident, DON, Social Worker, and Dietary Director. RN #1 stated that Resident #118 is obsessed with coffee, requesting at least 4-5 coffees on his breakfast tray. She explained that Resident #118 has a history of taking coffee from other's trays and had gone to the kitchen for coffee. RN #1 recalled that the director reminded him not to take coffee from other's trays. It was reported to her that Resident #118 went bizarre, yelling and screaming. She states that resident for the most part is easily calmed with the right approach as he does not like waiting or people telling him what to do. During interview with the Director of Rehabilitation on 10/26/2020 at 10:56am, she stated that she remembers the incident. She explained that Resident #118 came to the basement in a wheelchair, without a mask and she asked him to return to his unit. She reported that Resident #118 began screaming, yelling and cursing at her while attempting to enter the kitchen. She stated that she closed the door to the kitchen and again asked Resident #118 to return to his unit. She went on to say that Resident #118 instead went to the employee microwave and she reminded him that the microwave is for employees. Resident #118 then followed her down the hall cursing and swearing. She requested that he stop then she went to the PT room and held the door shut. RN #1 stated that Resident #118 then punched on the window and shattered it. She said that she notified the DON and could not recall who else was nearby. On 10/26/2020 at 10:35am, 1:10pm and 2:40pm the incident report was requested from the DON. At 2:40pm, the DON and the Regional DON gave an undated incident accident handwritten report to the surveyor for review. Review of the report showed that the report was undated and did not contain statements from Resident #118, witnesses or the accused. 483.12 (c)(2)-(4) .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey it could not be ensured that the facility notified all residents or the residents' representative(s) of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand. This was evident for 1 of 2 (Resident #140) residents reviewed for Hospitalization. The findings are: The facility policy and procedure titled, Discharge-Summary dated 9/2017 and revised 8/2019, describes the policy for anticipated discharges which includes writing a discharge summary and a post discharge plan. No policy or procedure was available for review regarding notification of unanticipated transfers and discharges. The facility Notice of Transfer/Discharge form was reviewed, which is completed by the nursing department at the time of an unanticipated transfer/discharge. Resident #140 was originally admitted to the facility on [DATE], was discharged to the hospital on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia, Dysphagia, Dependence on Renal Dialysis, and Diabetes. The Minimum Data Set (MDS; an assessment tool) dated 10/8/20 documented the resident has moderately impaired cognition and documented that Resident #140 requires assistance for activities of daily living. Review of a Nursing Progress Note dated 10/14/2020 documented that the resident was transferred to the hospital from the dialysis center. Resident #140 was admitted to the hospital with a diagnosis of Altered Mental Status. There was no documented evidence available for review that the resident or resident's family was issued a notice of transfer/discharge. On 10/26/20 at 3:00 PM, an interview was conducted with the Director of Social Work (DSW) who stated the other Social Worker (SW #1) would have completed the notification for Resident #140. She stated that she does not know the facility's policy regarding transfer/discharge. SW #1 was unavailable for interview. On 10/26/20 at 3:19PM a phone interview was conducted with the Resident #140's son who stated he did not receive a phone call from the facility regarding his father's transfer/discharge. He also said that he did not receive written notification regarding his father's transfer/discharge to the hospital. On 10/26/20 at 3:22PM the facility Administrator produced a binder containing previous transfer/discharge notifications and confirmed that notification was not sent to Resident #140 or the representative because the resident was transferred to the hospital directly from the dialysis center. During and interview on 10/26/20 at 4:04PM with the facility Assistant Administrator, he stated that he sends out the transfer/discharge notifications. He explained that he did not send them to Resident #140 or to Resident #140's family because the resident was transferred to the hospital directly from the dialysis center. 415.3(h)(1)(ii)(a)(b)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during a recertification survey, it cannot be ensured that the facility provided written notice of the facility's Bed Hold policy upon transfer to all residents or residents' representative(s). This was evident for 1 of 2 residents (Resident #140) reviewed for Hospitalization. The facility policy and procedure titled Bed Hold dated 3/2018 and revised 7/2019, documents the facility will provide written information regarding the bed-hold and return policy upon admission and prior to/at the time of hospitalizations or therapeutic leaves as soon as practicable following an emergency transfer. The findings are: Resident #140 was originally admitted to the facility on [DATE], was discharged to the hospital on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia, Hemiparesis, Dysphagia, Dependence on Renal Dialysis, and Diabetes. The Minimum Data Set (MDS; an assessment tool) dated 10/8/2020 documented that the resident has moderately impaired cognition and that Resident #140 requires staff assistance for activities of daily living (ADLs). Review of a Nursing Progress Note dated 10/14/2020 showed that Resident #140 was transferred to the hospital from the dialysis center. Resident #140 was admitted to the hospital with a diagnosis of Altered Mental State. There was no documented evidence available for review that Resident #140 or Resident #140's family was given written notice of the bed hold policy. On 10/26/20 at 03:00 PM, an interview was conducted with the Director of Social Work (DSW) who stated that the other Social Worker (SW #1) would have completed the Bed-Hold notification for Resident #140. She stated she does not know the facility's policy regarding bed-holds. SW #1 was unavailable for interview. On 10/26/20 at 03:19 PM a phone interview was conducted with Resident #140's son who stated he did not receive a phone call or written notice from the facility regarding the facility's bed-hold policy. On 10/26/20 at 03:22 PM the facility Administrator produced a binder containing previous bed hold policy notifications and confirmed that notification was not sent to Resident #140 or Resident #140's representative because the resident was transferred to the hospital directly from the dialysis center. On 10/26/20 at 04:04 PM an interview was conducted with the facility Assistant Administrator who stated that he sends the bed-hold notifications. He stated that he did not send them to Resident #140 or Resident #140's representative since this resident was transferred to the hospital directly from the dialysis center. 415.3(h)(4)(i)(a)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility provided the appropriate treatment and services to improve and /or prevent further decline in range of motion (ROM). Specifically, 1 of 4 residents (Resident # 29) reviewed for limited Range of Motion (ROM) did not have bilateral hand rolls in place to prevent further joint contracture as ordered by the physician. The findings are: Resident # 29 was admitted to the facility on [DATE]. Diagnoses included, but not limited to Quadriplegia, Generalized Muscle Weakness, Non-Traumatic Subarachnoid Hemorrhage, and Disorder of the Autonomic Nervous System. The 8/4/2020 Annual Minimum Data Set (MDS; an assessment tool) showed the resident's Brief Interview Mental Status (BIMS) could not be conducted and the resident required total dependence on staff with activities of daily living (ADLs). On surveyor observation, the resident was not responsive to verbal stimuli. Physician orders dated 9/28/2020 instructed the use of bilateral gauze/hand roll at all times. The gauze/hand roll is only to be removed for range of motion (ROM) exercises, hygiene and skin integrity checks. According to the 10/21/2020 updated Limited Physical Mobility Care Plan related to contracture and neurological deficits; the resident required bilateral gauze/hand roll to maintain joint integrity. The gauze/hand roll is only to be removed for range of motion (ROM) exercises, hygiene and skin integrity checks. Resident #29 was observed in bed on 10/19/2020 at 2:15PM with upper extremity contracture. There was no bilateral gauze/hand roll in place as ordered. Additional observations were conducted on 10/26/2020 at 11:15AM, 12:50PM and 1:39PM which revealed no evidence of the use of assistive devices for the resident's upper extremities as ordered. During an interview with the unit Registered Nurse Manager (RNM #1) on 10/26/2020 at 1:40PM, she stated that the resident received morning care and should have been wearing bilateral hand rolls to prevent further contracture of her hands. RNM #1 stated that the resident was not capable of refusing the device, and she did not know why the Certified Nursing Assistant (CNA) did not apply them. The RN was asked how she monitored and ensured CNAs are providing proper care to the residents and applying ordered devices to which she replied she makes daily rounds. In an interview with the assigned Licensed Practical Nurse (LPN #3) on 10/26/2020 at 1:53PM she stated that Resident #29 was supposed to wear hand rolls on both arms all the time to prevent contracture. They should be removed during hygiene. LPN #3 stated she did not notice the resident was not wearing the hand rolls. During an interview with the assigned CNA (CNA #2) on 10/26/20 at 2:08PM, she stated that Resident #29 required total care with ADLs, was not alert and was unable to make her needs known. CNA #2 stated that the resident uses a right-hand roll. CNA # 2 stated she provided care to the resident this morning at 8:30am. She stated that she took the hand rolls off but did not re-apply them. CNA #2 was asked why the hand rolls were not applied to the resident's hand. She stated that she knew she should have put them back on. Upon further interview, CNA #2 stated she may have been busy; she was not sure why she did not apply the hand rolls. In an interview with the Director of Rehabilitation (DR) on 10/26/2020 at 2:57PM, she stated that Resident #29 was evaluated and assigned to occupational therapy service (OT) on Saturday 10/24/2020 secondary to tightening of her bilateral hands. The DR stated the resident was supposed to wear hand rolls to prevent contracture. 415.12 (e) (1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey it could not be ensured that the facility staff followed proper hand hygiene and gloving techniques to prevent cross contamination and the spread of infection for 2 of 3 residents (Residents #113 and #115) reviewed for pressure ulcers. Specifically, 1) cross contamination of wound/wound supplies was observed during dressing change and 2) hand hygiene after removal of used gloves was not observed during wound care. The findings are: 1. Resident #113 was admitted to the facility on [DATE] with diagnoses including Major Depression, Generalized Muscle Weakness and Pressure Ulcer. The 7/1/2020 Annual Minimum Data Set (MDS; an assessment tool) showed the resident as experiencing moderately impaired cognition, requiring extensive assistance of staff support with Activities of Daily Living (ADLs) and at risk for Pressure Ulcers (PUs). Alteration in Skin Integrity Care Plan updated 10/1/2020, documented that the resident had a Stage 3 sacral PU. Goals included that the wound would show improvement through the next review date. Interventions included weekly wound assessment, daily wound monitoring and to notify the physician regarding signs or symptoms of infection and changes in skin status. Physician's Orders dated 10/22/2020 instructed staff to cleanse the Stage 3 sacral PU with Normal Saline, pat dry, apply Mupirocin 2 % Ointment, and cover with foam silicone border gauze sponges daily. During a wound care observation performed on Resident #113 on 10/23/2020 at 11:12AM, LPN #2 prepared the needed wound supplies, Normal Saline, 4 x 4 gauze and Mupirocin 2% Ointment on the treatment cart which was located outside the resident's door. LPN #2 sanitized her hands, then used her bare hands to open multiple drawers of the treatment cart to obtain more supplies. LPN #2 did not perform hand hygiene after touching the cart and removing the wound supplies from the treatment cart. Following this, LPN #2 used her bare hands to remove several pieces of unwrapped 4x4 gauze sponges from a multiuse gauze package and placed them on a tray on top of the treatment cart. LPN #2 then proceeded to the resident's room with the supplies. Upon approaching the resident's bed location, LPN #2 used her bare hands to close the bedside curtain. LPN #2 did not perform hand hygiene after touching the curtain. LPN #2 donned gloves, opened the bottle of Normal Saline and poured some on the 4x4 gauze sponges. At this point, Resident #113 needed to be changed. LPN #2 and the Registered Nurse Manager performed the personal care. LPN #2 then returned to complete the dressing change. After completion of the first sacral wound site, LPN #2 washed her hands and went back to the treatment cart to retrieve additional wound supplies for a second sacral wound site. LPN #2 used her bare hands to open several drawers of the treatment cart to obtain the supplies. LPN #2 did not perform hand hygiene. LPN #2 used her bare hands to remove several pieces of unwrapped 4x4 gauze sponges from a multiuse gauze package and returned to the resident with the gauze sponges and Mupirocin 2% Ointment to continue the wound care procedure. During the treatment of the second sacral wound site, LPN #2 donned gloves and used them to apply the Mupirocin 2% Ointment directly to the resident's sacral wound, then used the same gloves to apply the clean dressing. During an interview with LPN #2 on 10/23/2020 immediately following the wound care procedure, she stated that she should have washed her hands after touching the bedside curtain and after touching the treatment cart. LPN #2 stated she should not have used her bare hands to remove the 4x4 gauze sponges from the package and should have used a tongue depressor to apply the Mupirocin Ointment to the resident's wound. 2. Resident # 115 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Hypertension, and Pressure Ulcer (PU). According to the 3/23/2020 admission Minimum Data Set (MDS; an assessment tool), the resident had severe cognitive impairment and required extensive assistance of staff support with activities of daily living (ADLs). The MDS coded the resident at risk for PUs with an unstageable PU that was present on admission. Alteration in Skin Integrity Care Plan updated 10/10/2020 documented that the resident had a Stage 3 right heel PU. Goal included wound improvement in size through the next review date. Interventions included weekly wound assessment, offload wound with heel protectors, monitor wound daily and notify the physician regarding signs or symptoms of infection. Physician's Orders dated 10/13/2020 instructed staff to cleanse right heel wound with Normal Saline, pat dry, apply Collagen Hydrolysate Powder, dry protective dressing and wrap with Kling. During a wound care observation on 10/23/2020 at 10:42AM performed on Resident #115, the Licensed Practical Nurse (LPN #1) donned a pair of gloves and removed the soiled dressing from the resident's right heel wound. LPN #1 changed her gloves but did not perform hand hygiene following removal of the used gloves. LPN #1 then opened the bottle of Normal Saline and the container of Collagen treatment for the wound. With the same used gloves, LPN # 1 poured the Normal Saline onto several pieces of 4x4 gauze sponges, then used them to cleanse the resident's wound. LPN #1 utilized the same used gloves to apply the clean treatment and reapply the resident's heel protectors. During an interview with LPN #1 on 10/23/2020 immediately following the wound care procedure, she stated that she should have removed the used gloves and washed her hands. 415.19 (a) (1-3)

Sept 2018 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview and record review conducted during a recertification survey, the facility did not notify the primary care physician of a change in the medical condition of 1 of 2 residents (#46) reviewed for infection. Specifically, the resident had an acute onset of loose stool for multiple days while on an antibiotic prophylactic treatment for chronic Clostridium difficile (or C. diff; a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon) infection and the physician was not notified of this change in the resident's condition. The findings are: Resident #46 has diagnoses of Parkinson's disease and the medical condition of C. diff infection. The resident was provided nutritional support via a gastrostomy tube since March 2017. The resident's current physician's orders included the use of an antibiotic, Vancomycin oral solution 250 mg/5ml, give 2.5 ml every 6 hours prophylactically for 90 days, for the treatment of chronic C. diff. A review of the past physician's orders revealed that this antibiotic has been prescribed ongoing since at least June 2017. There was no documented evidence in the resident's medical record of any stool culture in the year 2017 and 2018. The comprehensive care plan dated July 2017 and in effect currently, noted that the resident was receiving an antibiotic and the goal was to have no clinical signs and symptoms of infection. Review of the bowel movement record for the months of August 2018 and September 2018 revealed that beginning 8/26/18 to 9/12/18, the resident experienced loose stools as follows: 8/26, 29, 9/2, 3, 4, 5, 6, 7, 8, 11, and 12. There was no documented evidence that the physician was notified of the onset of loose stools which could be a result of the tube feedings or possibly related to C. diff infection. The unit Registered Nurse manager (RN #1) was interviewed on 9/12/18 at 12:00 PM and she stated that the medical staff was not informed of this change in the resident's condition. The Nurse Practitioner was present at the time of this interview and stated that she would discontinue the Vancomycin and order laboratory work to determine if the resident was positive for C. diff. The primary care physician was interviewed on 9/13/18 at 12:30 PM and stated that she was not aware that the resident was experiencing loose stools. 415.3(e)(2)(ii)(b)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that a Comprehensive MDS (Minimum Data Set; a federally mandated process for clinical assessments of residents in Medicare or Medicaid certified nursing homes) was completed for each resident in accordance with the CMS (Centers for Medicare and Medicaid Services) guidelines for 3 of 5 residents (#1, #2, and #3) reviewed for resident assessment and for 2 of 2 Residents (#165 and #517) reviewed for respiratory care. Specifically, residents #1, #2, #3, #165 and #517 did not have an admission MDS completed within 14 days of admission to the facility. According to the MDS 3.0 RAI (Resident Assessment Instrument) User's Manual, Comprehensive admission Assessments must be completed no later than 14 days from the admission date (the admission date plus 13 calendar days). The findings are: Review of the MDS records revealed: - Resident (R) #1 was admitted to the facility on [DATE] and the required Comprehensive admission MDS Assessment with an ARD (Assessment Reference Date) of 8/21/18 was not completed until 9/8/18. - R #2 was admitted to the facility on [DATE] and the required Comprehensive admission MDS Assessment with an ARD of 8/20/18 was not completed until 9/8/18. - R #3 was admitted to the facility on [DATE] and the required Comprehensive admission MDS Assessment with an ARD of 8/13/18 was not completed until 9/4/18. - R #165 was admitted to the facility on [DATE] and the required Comprehensive admission MDS Assessment with an ARD of 8/17/18 was not completed until 9/6/18. - R #517 was admitted to the facility on [DATE] and the required Comprehensive admission MDS Assessment with an ARD of 8/31/18 was not completed until 9/11/18. The Registered Nurse MDS Coordinator was interviewed on 9/12/18 at 1:30 PM. She stated that the above MDS Comprehensive Assessments were not completed as they were trying to get caught up with the timely completion of the MDS Assessments. 415.11(a)(3)(i)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that, when not contraindicated, the recommendations of a Level II determination were incorporated into the plan of care for 1 of 1 resident (#106) reviewed for Preadmission Screening and Resident Review (PASARR) and emotional problems. The facility must ensure that it coordinates with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs. The findings are: Resident #106 was admitted to the facility on [DATE] and had diagnoses of Schizophrenia and Depression. The documentation of the Level I screening of the PASARR process dated 5/23/18 revealed that the resident had a serious mental illness and was being admitted for restorative services. The resident was evaluated on 5/24/18 for ongoing psychological therapy which was initiated on 5/31/18. The Initial Minimum Data Set (MDS; a comprehensive resident assessment tool) dated 5/30/18 showed that the resident was experiencing mood issues as evidenced by little pleasure in doing things, trouble with sleeping, having little energy, and poor appetite. The resident's total mood severity score was 8 which suggested that the resident had mild depression. A physician's note of 6/14/18 showed that the resident was being seen for persistent ileus, refusing to get out of bed, not participating/non-compliant with plan of care, and not eating. The plan was to send to send the resident to the hospital for further management of persistent ileus, depression and FTT (failure to thrive). The resident was readmitted to the facility on [DATE]. The psychiatrist evaluated the resident on 7/5/18 and noted that the resident had serious mental illness. He recommended that Celexa (an antidepressant) be increased from 10 mg to 20 mg. This recommendation was not implemented as the resident was already receiving 30 mg daily. The Quarterly MDS dated [DATE] showed that the resident's mood score had increased to 18 (defined in MDS as moderately severe depression) triggered by having little interest in doing things, depressed, problems with sleeping, little energy, poor appetite, and being easily annoyed. The psychologist documented on 7/28/18 that the resident showed limited to no interest in her treatment. She was dealing with major health issues and since returning to the facility from the hospital, the resident had gotten worse. The resident was more lethargic and found treatment more cumbersome than helpful. The resident was aware that she can always request treatment again if she were to feel the need. The Unit Manger/Registered Nurse (RN #1) documented on 7/31/18 that the resident status would be converted to long term placement. On 8/8/18, the next step of the PASARR process, Level II determination, was completed to determine if the resident was appropriate for long term placement in a nursing facility and if the resident needed specialized services. The Level II determinations were that: (1) the resident was appropriate for nursing home placement due to the need for assistance with medical care, psychiatric care, physical therapy, ADL (activities of daily living) assistance, and medication management and (2) for rehabilitative services and other supports to include: (a.) Ongoing psychiatric consultations and medication management by a psychiatrist or licensed prescriber - given psychiatric history,, ongoing psychiatric consultations are recommended every 4-6 weeks to monitor psychiatric symptoms and impact of psychotropic medications; (b.) Recovery-oriented clinical counseling focused on goal achievement by overcoming barriers due to mental illness. Given psychiatric history, she may benefit from weekly recovery clinical counseling to provide additional mental support and to assist with alleviating symptoms. The resident was observed in bed the first day of the survey on 9/6/18 at 2:58 PM. The resident appeared depressed and refused to talk to the surveyor. She then asked the surveyor to leave her room. Similar observations were made during the rest of the survey. There was no documented evidence that the interdisciplinary team re-approached the resident on the need to restart psychological counseling and that the resident was evaluated by the psychiatrist since 7/5/18 in light of the absence of supportive counseling and changes in medication management, self isolation and ongoing poor appetite. The resident's weight declined from 107 lbs. on 7/13/18 to 91 lbs. on 9/4/18. The Social Worker (SW) and the Unit Manager (UM) were interviewed on 9/13/18 at 10:05 AM. The SW stated that the resident had refused to communicate with her. She was asked if any attempts were made to restart psychological services for the resident. The SW provided no evidence that this was done. The SW was then asked, in light of the Level II recommendations and the fact that the resident was not receiving psychological services, what other treatment options were available to address the resident's psychiatric symptoms. She stated that the only other option was medication management. The UM provided no evidence that since 7/5/18 attempts have been made for another evaluation of the resident's medications by the psychiatrist. The UM did say that it has been very difficult getting services from the psychiatrist assigned to the resident. 415.11(e)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility did not ensure the physician's order for a tube fed resident was implemented according to the plan of care and that professional standards of practice were followed regarding the labeling of the tube feeding. This was evident for 1 of 2 residents reviewed for tube feeding (Resident #24). The facility policy for Enteral Feeding Pump Use dated January 2015 and updated on August 2018, under the heading Process, stated to write the date and label feeding set with type of formula, rate and time, and person hanging the feeding. The policy did not include any information regarding residuals. The ASPEN (American Society for Parenteral and Enteral Nutrition) Safe Practices for Enteral Nutrition indicated the following should be included on the formula label: Patient's name, date and time formula hung, rate of administration expressed as ml/hr, initials of who hung the formula, and the appropriate hang time. The findings are: Resident #24 was admitted to the facility on [DATE]. The current diagnoses included Failure to Thrive (FTT), Gastroesophageal Reflux Disease, Dementia and Gastrostomy Status. The Annual MDS (Minimum Data Set; a resident assessment tool) of 3/17/18 indicated the resident's weight was 106 lbs. and height was 57 inches. This MDS did not identify any significant weight loss or gain in the past 1-6 months. The nutritional approach was documented as feeding tube, mechanically altered and therapeutic diet. The total calories received through the tube feeding was documented as 51% or more. The Quarterly MDS of 6/13/18 Functional status was assessed as being totally dependent on staff for all activities of daily living (ADLs) and weighed 103 lbs. The care plan for Tube Feeding initiated on 9/27/16 indicated the resident required tube feeding due to dysphagia (inability to swallow), dementia, depression and FTT. The revision date was documented as 9/6/18, start of the survey period. The following interventions identified included to administer tube feeding and water flushes per RD (Registered Dietitian) recommendations and MD orders, check for tube placement and gastric contents/residual volume per facility protocol and record, and hold tube feeding if greater than 100 ml aspirate. The physician's order for tube feeding as it appeared on the September 2018 Medication Administration Record (MAR) indicated the feeding should be started at 6 AM and a second order indicated it should be finished at 2 AM or until the 1000 ml bottle is completed. The order for residuals on the MAR initiated on 9/20/16 indicated to check the residual feeding in the morning, hold if more than 100 ml, and call the physician. The order did not specify to document the amount of the residuals and there was no place on the MAR for that documentation. The resident's tube feeding was observed on 9/7/18 at 9:30 AM and revealed the tube feeding was running and the bottle was labeled with the date only. There was no other information included on the bottle. A second observation of the resident at 2:40 PM on the same date revealed the tube feeding had stopped infusing. The bottle appeared to be half full. Observation of the resident's tube feeding on 9/11/18 at 2:40 PM revealed Jevity 1.2 (a tube feeding formula) was running at 50 ml per hour. About half of the contents was finished. The bottle was dated 9/11 and there were no other identifiers on the bottle. The medication Licensed Practical Nurse (LPN) was interviewed at that time regarding the lack of identifiers on the label. She stated that it was the night nurse who started the feeding and that the feeding begins at 6 AM and finishes at 2 AM. When asked what should be written on the bottle if she were to start the feeding, she stated the resident's name, the date, the rate of the infusion, the time it was started and the nurses signature. Following surveyor intervention, the resident was observed on 09/12/18 10:30 AM lying in bed and the tube feeding was infusing. The label on the feeding bag had the required information (name, date, rate, time and initials of the nurse). The time on the bottle indicated the feeding started at 10 AM. In an interview with the LPN at that time she stated that she started the feeding at 10 AM because when she went into the resident's room she noticed the bottle was empty and a new one hadn't been started. When asked where the nurses sign that they take down the finished feeding and start the new feeding, she stated in the MAR. Review of the MAR indicated that there was a signature for taking down the feeding at 2 AM on 9/12/18 and there was no signature to indicate the feeding was started at 6 AM. The LPN stated the nurse must have forgotten to start the feeding before her shift was over. When asked how the nurse would document if the feeding was held due to residuals of more than 100 cc she stated there is nowhere for them to document that. The RN unit manager was interviewed on 9/12/18 at 11:30 PM and he stated that the out going nurses give report to the nurses coming in. That information should have been reported. He stated the nurse who signed for the feeding is relatively new and not a regular nurse on the unit. He further stated that if there were more than 100 cc of residuals, the feeding would have to be held for one hour. When he looked at the MAR, he noticed the instructions did not include recording the residuals and there was no place to record that information. The residuals were being signed that they had been done but there was no documentation indicating how much residual was observed. 415.11(c)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review conducted during a recertification survey, the facility did not provide the necessary care and services for 1 of 2 residents (#94) reviewed for respiratory care. Specifically, the facility did not provide Resident #94 who had a tracheostomy (an incision is made on the anterior aspect of the neck directly in the trach to create an artificial airway) with a device to enable the resident to speak more clearly and normally and/or communicate with others and to be more easily understood during conversations. The findings are: Resident #94 had diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Respiratory Failure. The Alteration in Respiratory Care Plan initiated on 4/20/18 and remained in effect at the time of review had no interventions regarding the method of communication that would be used for a resident with a tracheostomy tube. A Pulmonary Consult evaluation dated 7/24/18 had no evidence that the resident was assessed for possible communication options. There was no documented evidence, or produced upon request, that the resident was evaluated for the need of communication options in order to speak more clearly and normally and/or to communicate and be more easily understood during conversation. The resident was interviewed and observed on multiple occasions, including 9/6/18 at 11:31 AM and 9/13/18 at 1:50 PM using her finger to cover her trach to communicate. The resident stated the staff did not provide her with a communication board, or any other devices to communicate, or was provided education on how to communicate. The resident further stated that if she did not use her finger to block her trach to communicate, no sound would be produced upon speaking. Further room observation on both dates, as indicated above, revealed no evidence of communication devices including a board, pencil, or paper. The unit Registered Nurse manager (RNUM) was interviewed on 9/13/18 at 3:47 PM regarding the method of which the resident communicates with others. The RNUM stated that the resident communicated by placing her finger over her trach tube. The RNUM stated he was not sure if the resident received a communication device to speak. No evidence was provided by the facility upon request. 415.12(a)(1)(i-v)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that a resident received treatment and care in accordance with professional standard of practice. Specifically, the facility staff did not ensure that an old Nicotine patch was removed from the resident's skin prior to applying a new patch, possibly resulting in an extra dose of the medication for 1 of 3 residents (#415) reviewed for medication pass on 1 of 4 facility units (3rd Floor). The findings are: Resident #415 was admitted on [DATE] with diagnoses including Major Depressive Disorder and Hypertension. The physician order dated 9/10/18 had instructions to apply Nicotine 7mg/24-hour patch transdermal daily and remove per schedule for cessation of smoking. The resident hospital discharge record dated 9/10/18 revealed the resident was receiving Nicotine 7mg/24-hour transdermal patch daily for cessation of smoking which was applied 9/10/18 at 9:49 AM. A medication observation was conducted on 9/12/18 at 10:07 AM. The Licensed Practical Nurse (LPN #2) administered the resident's morning medications, including a Nicotine 7mg/24 transdermal patch. The LP LPN #2 was observed to remove an old Nicotine Patch from the resident's right arm deltoid area and applied a new one. LPN #2 then proceeded to the left deltoid area and immediately applied a new Nicotine patch. Upon inspection, it was noted that the old nicotine patch on the left deltoid area was not removed prior to applying a new one. It was revealed that the nicotine patch applied the day before was not removed resulting in 2 transdermal nicotine patches being applied. LPN # 2 removed both Nicotine patches, then applied the new one to the resident's back. Review of the Medication Administration Record (MAR) 9/1-31/2018 revealed that the first dose of the Nicotine 7mg /24-hour transdermal patch was applied to the resident's right arm on 9/11/18 at 10:09 AM. The box for instructions to remove the old patch had an X in the area without a signature. Review of the physician's orders that were in effect at the time of the review, revealed no additional instructions to apply additional Nicotine patch. LPN # 2 was interview on 9/12/18, at 9:25 AM following the above discovery and stated that the resident had on two 7mg Nicotine patch on his right upper arm/deltoid area, and the left upper arm/deltoid area. LPN # 2 stated that the left arm Nicotine Patch had no date on it. LPN # 2 stated that she removed both patches. LPN # 2 stated that one of the patch was from the hospital because the resident was a new admit to the facility. LPN # 2 further stated that the nurse who applied the patch on 9/11/2018 should have removed the old one prior to administering the new one. LPN # 3, who administered the first Nicotine patch, was interviewed on 9/12/18, 2:47 PM and stated that the resident was new to the facility. LPN # 3 stated that he applied the first Nicotine patch, with a date, to the resident's arm, on 9/11/18. LPN # 3 stated that was the first time he administered medication to the resident. LPN # 3 stated because the resident was new, he thought the resident did not have any patch in place. LPN # 3 stated that he thought that the person who did the admission assessment would have removed the patch. LPN # 3 further stated that the old patch should have been removed prior to applying a new one 415.12

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Complaint #NY225510 Resident #165 has diagnoses including Acute Respiratory Distress Syndrome, Status Post Tracheostomy and Pneumonia. The resident had a tracheostomy performed in July 2018 at a hospital and was readmitted to the facility on [DATE]. The admission MDS (Minimum Data Set; a resident assessment tool) of 8/17/18 documented that the resident had no cognitive impairment with daily decision making; required extensive assistance with most aspects of activities of daily living; and had been receiving oxygen therapy and tracheostomy care since admission. The Clinical Physician Orders dated 8/12/18 revealed continuous oxygen via trach mask at 10 liters/minute. This order was updated, following surveyor inquiry about trach care, and the following orders were added - trach care and suctioning every shift and change inner cannula daily Shiley #6 on 9/6/18 and 9/8/18, respectively. The resident was observed on 9/6/18 at 10:30 AM. The resident was not in any respiratory distress, showed slight dyspnea on exertion, and her color was pink. The resident had a Shiley #6 trach tube in place. The trach ties were clean and no skin irritations were noted underneath the trach ties or around the tracheostomy. There was no secretion and no odor was noted. Further observation at that time revealed there was no extra trach tube of the same and lesser size in case the trach tube is accidentally dislodged. Another observation was conducted on 9/7/18 at 9:45 AM and revealed that there was no extra trach tube of the same and lesser size and ambu bag at the bedside. The unit Licensed Practical Nurse (LPN #1) was interviewed on 9/7/2018 at 2:15 PM and she stated there was no trach tube inner cannula available in the facility when the resident was admitted on [DATE] so the staff was reusing the same inner cannula that was inserted at the hospital prior to readmission. She stated the facility now has the proper inner cannula trach tube and was stored in a locked closet located in the unit hallway opposite the resident's room and in the emergency cart near the dining room, following surveyor inquiry. The emergency cart was inspected with the unit Licensed Practical Nurse (LPN #5) on 9/11/2018 at 3:20 PM. LPN #5 stated that the facility corrected the error by placing the ambu bag and extra trach tubes at the bedside to ensure immediate replacement to maintain a patent airway in case of case of accidental dislodgement of the trach tube. 415. 12(k)(4)(5)(6) Based on observation, interview, and record review conducted during a recertification and abbreviated (#NY00225510) survey, the facility (1.) did not provide for 1 of 2 residents (#94), reviewed for respiratory care, a device to enable the resident to speak more clearly and to be more easily understood during conversation with others while having a tracheostomy tube. Additionally, (2.) manual resuscitative devices (ambu bags) and extra tracheostomy tube sets were not easily accessible in case of an emergency for 2 of 3 residents (#94 and #165) with a tracheostomy (trach) tube reviewed for respiratory care. A tracheostomy is a surgical procedure which consist of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. The facility Tracheostomy Care policy updated on 8/18/17 stated that a suction machine, suction catheters, trach tube of the same size and smaller size and ambu bag should be maintained at bedside at all times in clean and in working condition. This policy also included guidelines for daily tracheostomy care such as cleaning stoma, clearing the tracheostomy of secretions, changing inner cannula and replacing neck tie. The findings are: 1. Resident # 94 had diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Respiratory Failure. The care plan for Alteration in Respiration initiated on 4/20/18 and remained in effect at the time of review had no interventions regarding the method of communication that would be used for a resident with a tracheostomy tube, or the need of accessible resuscitative devices to be used in case of an emergency. A Pulmonary Consult evaluation dated 7/24/18 had no evidence that the resident was assessed for possible communication options. Resident #94 was interviewed on 9/6/18, at 11:31 AM, and stated that there was no extra tracheostomy tube set available at the bedside in case of an emergency. Room observation was conducted at the time of the resident interview, as indicated above, with the resident's permission, and the assistance of a Certified Nursing (CNA # 2) and revealed no evidence of an extra tracheostomy tube set of the same or smaller size or an ambu bag at the bedside for use in the case of an emergency. A follow up room observation was conducted on 9/12/18 at 2:33 PM, with the assistance of Licensed Practical Nurse (LPN #4) revealed an extra trach tube of the same size. There was no ambu bag or a trach tube of lesser size in case the size being used by the resident does not fit if it is accidentally dislodged. LPN #4 was interviewed on 9/12/18 at the time of the room observation, as indicated above, and stated that the resident should have had an extra inner cannula available at the bedside. LPN # 4 stated she was not sure if ambu bag should have been at the bedside but one was available on the emergency cart in the unit dining room. A follow up room observation was conducted on 9/13/18 at 11:05 AM with the Registered Nurse Unit Manager (RNUM) revealed an extra Shiley #4 tracheostomy tube and an ambu bag at the resident's bedside. There was no lesser size trach tube available at that time. The resident was observed on multiple occasions, including 9/6/18 at 11:31 AM and 9/13/18 at 1:50 PM using her finger to cover her trach to communicate. The resident stated the staff did not provide her with a communication board, or any other devices to communicate, nor provided education how to communicate. The resident further stated that if she did not use her finger to communicate, sound would not be produced upon speaking. Further room observation revealed no evidence of communication devices such as a board, pencil, and paper. The RNUM was interviewed on 9/13/18 at 2:40 PM regarding the method of which the resident communicates with others. The RNUM stated that the resident communicated by placing her finger over her tracheostomy tube. The RNUM stated he was not sure if the resident received a communication device to speak. No evidence was provided upon request from the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that 1 of 1 resident (#106) reviewed for behavioral / emotional problems was provided the appropriate services to correct assessed problems and to attain the highest practicable mental and psychosocial well-being. The finding is: Resident #106 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Depression and Failure to Thrive (FTT). The documentation of the Level I screening of the PASARR process dated 5/23/18 revealed that the resident had a serious mental illness and was being admitted for restorative services. The resident was evaluated on 5/24/18 for ongoing psychological therapy which was initiated on 5/31/18. The Initial Minimum Data Set (MDS; a comprehensive resident assessment tool) dated 5/30/18 showed that the resident was experiencing mood issues as evidenced by little pleasure in doing things, trouble with sleeping, having little energy, and poor appetite. The resident's total mood severity score was 8 which suggested that the resident had mild depression. The Mood care plan dated 5/29/18 and remained in effect after the initial MDS of 5/30/18 showed that the goals for the resident were to verbalize and demonstrate improved mood and participate in activities. The interventions to achieve these goals included to administer medications as ordered, encourage activity participation, provide opportunity to express self, psychological services and refer for psychiatry evaluation as needed. The psychotropic medications prescribed were Celexa, Olanzapine, Remeron and Lorazepam. The behavior care plan at the time of the Initial MDS assessment noted that the resident was refusing to get out of bed and refusing meals. The behavioral goals for the resident were to improve in care participation, exhibit fewer or no episodes of behavioral activity, not to harm self, and seek out care givers when agitation occurs. The interventions included to administer medications, contract with resident as needed, determine cause of behavior and remove resident as needed, distract with activities, document all behaviors, and attempt to identify pattern to target interventions. The interdisciplinary notes revealed the following problems mood symptom (poor appetite) and lack of psychiatric response for an evaluation: - 6/7/18 dietary note: Intake generally poor at meals and for supplements. Past psychiatric hospital staff reported that history of good appetite and acceptability of a wide variety of food; - 6/7/18- Psychiatric consult pending - 6/8/18 Physician note: Plan to increase Remeron (for appetite) to 15 mg at bedtime for appetite; may need tube feeding. - 6/12/18- Refusing to eat, shower, to get out of bed, psychiatry consult pending. physician was called and left message to come for psychiatry evaluation as soon as possible, intravenous fluid started. - 6/12/19 MD Note: nurse asked to see resident for poor oral intake, psychiatry consult pending. - 6/13/18 MD note: refused to discuss why she is depressed. - 6/14/18 Nursing note: resident seems very depressed psychiatrist called to come as soon as possible. - 6/14/18 MD note- nurse asked to see patient for persistent ileus, refusing to get out of bed, does not participate/non-compliant with plan of care, not eating. Refused to say why depressed and stated she wants Paxil. Plan to send to emergency room for further management and evaluation of persistent ileus, depression and FTT, and to get out of bed. There was no documented evidence that the resident was evaluated by the psychiatrist prior to transfer to the hospital on 6/14/18. The resident was readmitted to the facility on [DATE]. The psychiatrist evaluated the resident on 7/5/18 and noted that the resident had serious mental illness. He recommended that Celexa be increased from 10 mg to 20 mg. This recommendation was not implemented as the resident was already on 30 mg daily as reflected on the evaluation by the Nurse Practitioner. The Quarterly MDS dated [DATE] showed that the resident's mood score had increased to 18 (defined in MDS as moderately severe depression) triggered by having little interest in doing things, depressed, problems with sleeping, little energy, poor appetite, and being easily annoyed. The psychologist documented on 7/28/18 that the resident showed limited to no interest in her treatment. She was dealing with major health issues and since returning to the facility from the hospital, the resident had gotten worse; she was more lethargic and found treatment more cumbersome than helpful. The resident was aware that she can always request treatment again if she were to feel the need. The unit Registered Nurse (RN #1) manager documented on 7/31/18 that the resident's status would be converted to long term placement. The second step of the Preadmission Screen Annual Resident Review process, Level II determination was completed on 8/8/18 to determine if the resident was appropriate for long term placement in a nursing facility and if the resident needed specialized services. The Level II determinations were that (1.) the resident was appropriate for nursing home placement due to the need for assistance with medical care, psychiatric care, physical therapy, ADL (activities of daily living) assistance, and medication management and (2.) for rehabilitative services and other supports to include (a.) Ongoing psychiatric consultations and medication management by a psychiatrist or licensed prescriber - given psychiatric history,, ongoing psychiatric consultations are recommended every 4-6 weeks to monitor psychiatric symptoms and impact of psychotropic medications and (b.) Recovery-oriented clinical counseling focused on goal achievement by overcoming barriers due to mental illness. Given psychiatric history, she may benefit from weekly recovery clinical counseling to provide additional mental support and to assist with alleviating symptoms. There was no documented evidence that the interdisciplinary team re-approached the resident on the need to restart psychological counseling and that the resident was evaluated by the psychiatrist since 7/5/18 in light of the absence of supportive counseling and changes in medication management, self isolation and ongoing poor appetite. The resident's weight declined from 107 lbs. on 7/13/18 to 91 lbs. on 9/4/18. The resident was observed in bed the first day of the survey on 9/6/18 at 2:58 PM. The resident appeared depressed and refused to talk to the surveyor. She then asked the surveyor to leave her room. Similar observations were made during the rest of the survey. The Nurse Practitioner and the Unit Manager were interviewed in the afternoon of 9/12/18 regarding the error noted on the psychiatric evaluation. They offered no explanation as to why the medical staff did not address the error by the psychiatrist and the need to make changes to the resident's psychotropic medication management. The Social Worker (SW) and the Unit Manager (UM) were interviewed on 9/13/18 at 10:05 AM. The SW stated that the resident had refused to communicate with her. She was asked if any attempts were made to restart psychological services for the resident. The SW provided no evidence that this was done. The SW was then asked, in light of the Level II recommendations and the fact that the resident was not receiving psychological services, what other treatment options were available to address the resident's psychiatric symptoms. She stated that the only other option was medication management. The UM provided no evidence that since 7/5/18 attempts have been made for another evaluation of the resident's medications by the psychiatrist. The UM did say that it has been very difficult getting services from the psychiatrist assigned to the resident. 415.12(f)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, it was determined for 1 of 5 residents (#90) selected for unnecessary medications and psychotropic medications review that the resident's medication regimen was free of unnecessary medications. Specifically, gradual dose reduction (GDR) was not implemented and there was lack of sufficient documentation contraindicating GDR for the use of an antipsychotic medication (Seroquel; used to treat schizophrenia, bipolar disorder and depression). The finding is: Resident # 90 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Dementia with behavioral disturbance, Unspecified Psychosis, and Depression. The Quarterly MDS (Minimum Data Set Assessment; a resident assessment tool) of 7/20/18 indicated that the resident had moderately impaired cognitive skills for daily decision making and had moderate depression. This MDS indicated that the resident received antipsychotics on a routine basis, GDR had not been attempted, and the physician documented on 2/15/18 that GDR was clinically contraindicated. The resident had been receiving antipsychotic, antianxiety and antidepressant medications during the [NAME] 7 days of this assessment period. The Physician Orders form included Buproprion HCI (Buspar) 10mg give 1 tablet 3 times a day for anxiety ordered on 3/31/18, Quetiapine Fumarate (Seroquel) Tablet 25mg give 12.5mg by mouth two times daily for Psychosis ordered on 4/16/17, and Celexa 20mg daily for depression ordered on 4/16/17. The Psychiatry Assessment and Plan of 2/15/18 indicated the resident was focused on his need for therapy as he wanted improved power on his left side, reported dissatisfaction with not receiving therapy, was future oriented with no suicidal/ homicidal thoughts, the diagnosis indicated the resident appears motivated to improve muscle strength as he is seeking therapy, and that no GDR was planned at that time for reasons just stated. The Weekly Behavior Monitoring Notes dated 5/4/18, 6/15/18, 6/22/18, and 9/12/18 documented no change from residents baseline behavior noted. A signed 8/1/18 Inter-disciplinary Behavior Psychiatric Assessment indicated the resident never had behaviors including screaming, verbal, sexual, and physical aggression, hitting, kicking, biting, and that he was not a danger to self or others. The Pharmacy Regimen Review done on 4/24/18, 5/30, 6/27, 7/22, and 8/27/18 indicated no irregularities were found. The unit Registered Nurse manager (RN #2) was interviewed on 9/12/18 at 12:23 PM and she stated that since the resident was transferred to her unit in January 2018, he did not exhibit behaviors and that the resident should be a candidate for a psychotropic medication dose reduction. When asked further, RN #2 was unable to provide documentation that indicated the resident had been evaluated by a psychiatrist or that a gradual dose reduction was addressed. The Director of Nursing (DON) was interviewed on 9/13/18 at 4:13 PM and she stated that the resident had been a behavior problem in the past but had settled in. The DON was unable to provide documentation between April 2017 and February 2018 to address the use of the Seroquel including GDR. The Psychiatry Assessment record dated 9/13/18 documented that the resident was alert, not agitated, did not appear depressed, was not sedated and a question of possible Psychotic Depression. The psychiatrist recommended to discontinue the morning dose of Seroquel and to reassess the resident. 415.18(c)(1)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during a recertification survey, the facility did not ensure that medications were stored and labeled in accordance with currently accepted professional standard of practice. Specifically, two insulin pens stored in 1 of 4 medication carts (3rd Floor) were observed to be opened and in use beyond the manufacturer's recommendation of 28 days after opening. The finding is: The manufacturer's recommendation states that Lantus Insulin pens and Humalog Insulin pens are to be discarded 28 days after opening. Observation of the medication storage was conducted on [DATE] at 2:30 PM. One of the 2 medication carts on the 3rd Floor was observed to have two insulin pens. The Lantus Solostar was opened on [DATE] and expired on [DATE] and the Humalog insulin was opened on [DATE] and expired on [DATE]. These insulin preparations were being used by two different residents on the unit namely, Residents #515 and #113. The medication Licensed Practical Nurse (LPN #1) was interviewed on [DATE] at 3:30 PM and she stated that she forgot to check the dates on the insulin pens before the medication was administered. 415.18(d)

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record conducted during a recertification survey, the facility did not ensure that measures were in place to prevent the spread of infection and cross contamination for 1 of 2 residents, with tracheostomy tubes, who were reviewed for respiratory care (Resident #94). The resident was observed performing her own tracheostomy (trach; a type of airway inserted directly into the trachea) care using improper technique, and without using proper hand hygiene, potentially contaminating the tracheostomy. The findings are: Resident #94 had diagnoses and conditions including Chronic Obstructive Pulmonary Disease and Respiratory Failure. The 7/23/18 Quarterly Minimum Data Set (a resident assessment tool) documented that the resident had no cognitive impairment. The resident was interviewed on 9/13/18 at 1:50 PM and stated that she was taught by a doctor in the hospital to perform her own trach care and not by the facility staff. During the 9/13/18 interview, as indicated above, the resident was asked to verbally demonstrate how she performed trach care. The resident had a small, opened, uncovered, undated dressing kit with gauze sponge, and a small brush, along with a small bottle of normal saline solution with 9/13/18 date inscribed on the bottle, placed on her bedside table. Without washing her hands, the resident removed the tracheostomy inner cannula, and placed it on a piece of napkin that was on her table. The resident then placed the inner cannula directly into the entire bottle of saline, shook it around, removed it, then used the brush to remove the yellowish secretions from it. Following the procedure, the resident returned the inner cannula back to her trach site. The resident used the soiled napkin to remove the secretion from the tip of the brush, then returned it to the dressing kit. Upon further interview, the resident stated she used the normal saline and the trach kit all day. The resident stated that she received a new trach kit and a new bottle of normal saline solution each day on the night shift. The Alteration in Respiratory Care Plan initiated on 4/20/18 and remained in effect at the time of review had no instructions how the resident should perform her own trach care. A Non-Compliant Care Plan initiated 5/7/18 and revised 7/9/18 documented that the resident refused trach care and inner cannula change. There was no evidence in the care plan that the staff trained or attempted to train the resident on how to perform her own trach care. There was no documented evidence, or produced upon request, that the resident was trained on how to perform her own trach care to prevent the spread of infection and cross contamination of her trach. The Licensed Practical Nurse (LPN #4) was interviewed on 9/12/18 at 2:33 PM and stated the resident refused the nurses from performing trach care. LPN #4 stated that the resident performs her own trach care. The Registered Nurse Manager (RNM) was interviewed on 9/13/18 at 2:40 PM and stated that the resident refused the nurses from performing trach care. The RNM stated he was not sure if anyone trained the resident on trach care. 415.19 (a) (1-3)

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most New York facilities.
• 18% annual turnover. Excellent stability, 30 points below New York's 48% average. Staff who stay learn residents' needs.

Concerns

• 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade D (45/100). Below average facility with significant concerns.

Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Northern Riverview Health Care, Inc's CMS Rating?

CMS assigns NORTHERN RIVERVIEW HEALTH CARE, INC an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within New York, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Northern Riverview Health Care, Inc Staffed?

CMS rates NORTHERN RIVERVIEW HEALTH CARE, INC's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 18%, compared to the New York average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Northern Riverview Health Care, Inc?

State health inspectors documented 40 deficiencies at NORTHERN RIVERVIEW HEALTH CARE, INC during 2018 to 2025. These included: 40 with potential for harm.

Who Owns and Operates Northern Riverview Health Care, Inc?

NORTHERN RIVERVIEW HEALTH CARE, INC is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 182 certified beds and approximately 179 residents (about 98% occupancy), it is a mid-sized facility located in HAVERSTRAW, New York.

How Does Northern Riverview Health Care, Inc Compare to Other New York Nursing Homes?

Compared to the 100 nursing homes in New York, NORTHERN RIVERVIEW HEALTH CARE, INC's overall rating (1 stars) is below the state average of 3.0, staff turnover (18%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Northern Riverview Health Care, Inc?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Northern Riverview Health Care, Inc Safe?

Based on CMS inspection data, NORTHERN RIVERVIEW HEALTH CARE, INC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New York. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Northern Riverview Health Care, Inc Stick Around?

Staff at NORTHERN RIVERVIEW HEALTH CARE, INC tend to stick around. With a turnover rate of 18%, the facility is 27 percentage points below the New York average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 25%, meaning experienced RNs are available to handle complex medical needs.

Was Northern Riverview Health Care, Inc Ever Fined?

NORTHERN RIVERVIEW HEALTH CARE, INC has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Northern Riverview Health Care, Inc on Any Federal Watch List?

NORTHERN RIVERVIEW HEALTH CARE, INC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 182
Avg. Residents: 179
Occupancy: 98.4%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
Low Turnover: +5
40 Deficiencies: -10
Final Score: 45/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 335418