Does JEWISH HOME OF CENTRAL NEW YORK have any serious inspection findings?

Yes, JEWISH HOME OF CENTRAL NEW YORK has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 47 total deficiencies from recent inspections.

What are the staffing levels at JEWISH HOME OF CENTRAL NEW YORK?

JEWISH HOME OF CENTRAL NEW YORK has a one-star staffing rating from CMS with 0.44 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 JEWISH HOME OF CENTRAL NEW YORK located?

JEWISH HOME OF CENTRAL NEW YORK is located in SYRACUSE, NY. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does JEWISH HOME OF CENTRAL NEW YORK have?

JEWISH HOME OF CENTRAL NEW YORK has 132 certified beds.

Who owns JEWISH HOME OF CENTRAL NEW YORK?

JEWISH HOME OF CENTRAL NEW YORK is a non profit - corporation facility and operates independently (not part of a chain).

How does JEWISH HOME OF CENTRAL NEW YORK compare to other nursing homes?

JEWISH HOME OF CENTRAL NEW YORK has a 1-star overall rating, which is below average compared to other nursing homes in NY. Families should carefully review inspection findings and consider alternatives.

JEWISH HOME OF CENTRAL NEW YORK

Q: What is JEWISH HOME OF CENTRAL NEW YORK's CMS rating?

JEWISH HOME OF CENTRAL NEW YORK has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Do nurses at JEWISH HOME OF CENTRAL NEW YORK stick around?

JEWISH HOME OF CENTRAL NEW YORK has high staff turnover at 56%. High turnover can mean less continuity of care as staff change frequently.

Q: Was JEWISH HOME OF CENTRAL NEW YORK ever fined?

Yes, JEWISH HOME OF CENTRAL NEW YORK has been fined $132,140 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is JEWISH HOME OF CENTRAL NEW YORK on any federal watch list?

No, JEWISH HOME OF CENTRAL NEW YORK is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

4101 E GENESEE ST, SYRACUSE, NY 13214 · (315) 446-9111

Non profit - Corporation 132 Beds Independent Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

3/100

#522 of 594 in NY

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Last Inspection: May 2024

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

Overview

The Jewish Home of Central New York has received a Trust Grade of F, indicating significant concerns about the quality of care provided at the facility. Ranking #522 out of 594 in New York places it in the bottom half, and #10 out of 13 in Onondaga County suggests that only two local options are better. The trend is worsening, with issues increasing from 4 in 2023 to 17 in 2024. Staffing is a critical concern, as they have a poor rating of 1 out of 5 stars and a high turnover rate of 56%, significantly above the state average of 40%. Additionally, the facility has incurred $132,140 in fines, which is higher than 96% of New York facilities, indicating ongoing compliance problems. RN coverage is also concerning, as it is lower than 79% of state facilities, meaning fewer registered nurses are available to catch potential health issues. Specific incidents include a resident who fell and was left unattended for two and a half hours and another resident who developed a severe pressure ulcer due to inadequate care. While the facility has some average quality measures, the overall picture raises significant red flags for families considering this home for their loved ones.

Trust Score: F
In New York: #522/594
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $132,140 in fines. Lower than most New York facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for New York. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 47 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2023: 4 issues

2024: 17 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below New York average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 56%

10pts above New York avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $132,140

Well above median ($33,413)

Significant penalties indicating serious issues

Staff turnover is elevated (56%)

8 points above New York average of 48%

The Ugly 47 deficiencies on record

1 life-threatening 1 actual harm

May 2024 17 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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Based on observation, record review, and interview during the recertification and abbreviated (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of quality of life for 13 of 13 residents (Residents #59 and 12 anonymous residents) reviewed. Specifically, Certified Nurse Aide #36 was observed speaking loudly near the main dining room about Resident #59's urinary drainage device; and multiple staff were observed using their personal communication devices in care areas during working hours. Findings include: The facility Employee Handbook revised 3/1/2015, documented staff were not permitted to use cell phones during work hours and individual earphones were prohibited. The facility policy, Safe, Clean, Homelike Environment revised 3/2024, documented the facility was committed to providing residents with a homelike environment that de-emphasized the institutional character of the setting. The facility policy, Resident Rights revised 6/2000, documented residents had a right to personal privacy and confidentiality of their personal and clinical records. 1) Resident #59 had diagnoses including urinary tract infection and obstructive uropathy (blocked urine flow). The 5/6/2024 Minimum Data Set assessment (a health status screening and assessment tool) documented the resident had severely impaired cognition, had an indwelling catheter (drains urine from the bladder), and was dependent for toileting. The comprehensive care plan initiated 3/20/2024, documented an alteration in elimination related to use of a urinary drainage device. Interventions included the drainage bag was kept covered for dignity. During an observation on 5/20/2024 at 12:24 PM, Certified Nurse Aide #36 brought Resident #59 into the dining room. The resident stated they needed to use the bathroom. Certified Nurse Aide #36 replied loudly to the resident that they had just gotten off the bed pan and had a catheter. There were 4 residents seated nearby. During an interview on 5/21/2024 at 1:38 PM, Registered Nurse Manager #14 stated staff should not talk about resident specific information such as catheters and bed pans when in the dining room as that was not dignified or homelike. An attempt was made on 5/22/2024 at 11:48 AM to conduct a phone interview with Certified Nurse Aide #36, however, the call was not answered. 2) During a resident meeting on 5/16/2024 at 11:11 AM, 12 of 12 anonymous residents reported staff frequently used their cell phones and earbuds in resident care areas. The residents felt staff pretended they could not hear them when they utilized their personal communication devices. During an observation on 5/20/2024 at 9:32 AM, Licensed Practical Nurse #2 was seated with residents at a dining room table during the breakfast meal and was looking at their phone. They did not interact with residents. During an interview on 5/22/2024 at 8:55 AM Licensed Practical Nurse Unit Manager #1 stated cell phones, were not allowed in resident care areas, and there were no exceptions. If staff were on their phones, they were not attending to the needs of the residents. That could result in resident injury, an elopement, or other worse case scenarios. It was also a violation of resident privacy and confidentiality to have personal cell phones in resident care areas. During an observation on 5/21/2024 at 11:01 AM, Certified Nurse Aide #32 was observed to sitting in the television lounge area on the unit using their personal cell phone. They stated they should not be using their personal cell phones in resident care areas. During an interview on 5/21/2024 at 1:38 PM, Registered Nurse Manager #14 stated staff should not be using their personal cell phones in resident care areas. 10NYCRR 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview during the recertification and abbreviated (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #48) reviewed. Specifically, Resident #48 did not have the capacity to make medical decisions and their health care proxy (person appointed to make healthcare decisions when the individual can no longer do so) was not notified when the resident developed a wound which required treatment. Findings include: The facility policy, Criteria for Assessing Changes in Resident Condition revised 10/11/2023 documented a change in condition was defined as an improvement or decline in physical, mental and/or psychosocial status. Skin breakdown and open areas were included but not limited to examples of a condition change. The licensed nurse notified the provider for further orders, management, or treatment. New orders were initiated by the licensed nurse and a change of condition progress note was documented in the electronic medical record. The resident's family was notified, and family notification was documented in the progress note. Resident #48 had diagnoses including Alzheimer's disease (a progressive disease that alters memory) and urinary incontinence. The 4/28/2024 Minimum Data Set Assessment (a health status screening and assessment tool) documented the resident had severely impaired cognition, was dependent on staff for toileting, hygiene, bed mobility and transfers with a mechanical lift, was at risk for pressure ulcers, and had applications of ointments/ medications other than to feet. The resident's admission Face sheet documented the resident had two family members who were designated as both Health Care Proxies and emergency contacts. The comprehensive care plan initiated 1/6/2021 and reviewed 12/28/2023 documented the resident was at high risk for skin breakdown related to decreased mobility and incontinence. Interventions included incontinence care, certified nurse aide was to report skin conditions daily during care and report any abnormalities to the nurse, maintain turn and position schedule every 2-4 hours, and use skin protectant/ barrier when performing perineal care (washing genital and rectal areas). The 10/18/2023 Assistant Director of Nursing wound team progress note documented the resident had a 3.5 centimeter by 2 centimeter open area to the left buttocks and a 3.5 centimeter by 2 centimeter open area to the right buttocks. The wounds were new and the Assistant Director of Nursing recommended treatment with collagenase (an ointment used to remove dead tissue) and continue current treatment for heels. The 10/18/2023 physician order documented apply collagenase topical ointment 250 unit/ gram once daily to 3.5 centimeter by 2 centimeter open areas to left and right buttocks after cleansing with normal saline and patting dry, then cover with a foam dressing. There was no documented evidence the resident's Health Care Proxies/emergency contacts were notified of the new bilateral buttock's wounds and treatment identified by the Assistant Director of Nursing. During an observation on 5/20/2024 at 11:54 AM, Certified Nurse Aides #20 and #21, and Licensed Practical Nurse #18 provided incontinence care to the resident. A reddened area approximately the size of a ping pong ball was noted to the middle right buttocks. Licensed Practical Nurse #18 said this area was reported to them this morning by an unidentified certified nurse aide and they had not seen it yet. Licensed Practical Nurse #18 left the room and returned with the Assistant Director of Nursing. The Assistant Director of Nursing stated the area to the buttocks was new and this was moisture associated skin damage. Licensed Practical Nurse #18 applied the ordered zinc ointment per the Assistant Director of Nursing's direction. There was no documented evidence through 5/21/2024 the resident's Health Care Proxies/emergency contacts were notified of the new buttocks wound identified on 5/20/2024 by the Assistant Director of Nursing. During a telephone interview on 5/22/2024 at 8:48 AM the resident's designated Health Care Proxy/emergency contact stated in 10/2023, they observed wounds on the resident's buttocks during incontinence care that they were never notified of and wondered how long they had been there. They were not aware of any current wounds to the buttocks. They visited often and stated they did not get updated on any wounds but asked to see the chronic foot wounds when they visited. They thought they should be updated on new wounds. They attended care plan meetings and was only updated on the resident's wounds during the meetings when they asked about them. During an interview on 5/22/2024 at 10:07 AM Licensed Practical Nurse Unit Manager #17 stated families were notified of any change in condition. Family should also be notified of new wounds and changing wounds. It was important for quality of life and permission for treatment. Resident #48 was not cognitively intact, and their family should be notified. The resident's family member liked to be involved and attended all outside wound appointments in the past. If the resident's family was notified for any reason, it should be documented in a progress note. During an interview on 5/22/2024 at 10:42 AM the Assistant Director of Nursing stated family representatives were updated on change of condition that included incidents, new and changing wounds, as well as medication changes and care plan changes. They did not notify Resident #48's representative of the buttocks wounds they identified on 10/18/2023 or the new buttock wound identified on 5/20/2024 and they should have. 10NYCRR 415.3(e)(2)(ii)(b,c)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on record review and interview during the recertification and abbreviated (NY00326481 and NY00334060) surveys conducted 5/16/2023-5/23/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 2 of 3 residents (Resident #48 and 119) reviewed. Specifically, Resident #48 had an unwitnessed fall that was not investigated; and Resident #119 had injuries of unknown origin that were not thoroughly investigated. Findings included: The facility policy, Falls Management and Prevention revised 10/11/2023, documented after a fall, the licensed nurse initiated an incident report and staff provided written statements. Written statements included time and location the resident was last seen, behavior pattern of the resident, what the resident was doing at the time of the incident if known, and any change in activity of daily living status. The supervisor on duty contacted the provider and the resident's family and documented in the medical record and included the time and the person spoken with. A resident was evaluated 72 hours post fall and included vital signs every shift and neurological check (evaluates neurological function) protocol. The facility policy, Incident Occurrence and Reporting created 10/11/2023, documented the facility was responsible to investigate all incidents and maintain records of each investigation. The facility staff was responsible for investigating and reporting alleged violations of mistreatment, neglect, and abuse, including injuries of unknown source to the New York State Department of Health. The unit licensed practical nurse or Nursing Supervisor would initiate an incident report for the following occurrences including falls, bruises, and injuries of unknown origin. The incident reports would be filled out correctly, complete, and document the time and location of incident; the location and description of injury; vital signs; the cause of the incident, if known; any statements made by the resident and any witness; and the time and date family and medical were notified. The unit nurse or designee would complete the Accident and Injury report, copy any pertinent parts of the chart and staff statements. These documents would be delivered to the Director of Nursing or designee for review. The Director of Nursing and/or designee would review the incident and follow up for completion and appropriateness. Obtain and track all incident reports within a reasonable time frame to ensure prompt review. Conduct follow up investigations to establish root cause, make determinations of identifiable or unidentifiable reasonable cause. The interdisciplinary team would review all adverse incidents at team meeting during morning report. The Director of Nursing/Administrator would examine incident reports and investigations for completeness and accuracy and file reports according to the facility, state, and federal regulations. 1) Resident #119 was admitted with diagnoses including Parkinson's disease (a progressive neurological disorder), neurocognitive disorder with Lewy bodies (a type of dementia), and repeated falls. The 1/13/2024 Minimum Data Set Assessment (a resident assessment tool) documented the resident had severely impaired cognition, rejected care 1-3 days, had functional limitation to one arm, required substantial/maximal assistance with upper and lower body dressing, supervision or touching assistance with sit to stand, chair/bed-to-chair transfers, and walking 10-150 feet. The resident had 2 or more falls since admission/entry or reentry or prior assessment with no injury or injury (except major). The 10/6/2023 comprehensive care plan documented the resident had a cognitive deficit related to Lewy Body dementia. Interventions included independent with bed mobility, ambulation, and transfers; provide assistance with bed mobility, transfer with staff assistance, ambulates self at times/ staff assist of 1 or 2 for balance. The resident was at risk for falls. Interventions included investigate cause of fall immediately, evaluate pattern of falls if the resident fell more than once, anticipate resident needs, keep family informed of falls, use appropriate assistive devices and level of assistance as recommended, and ensure proper footwear. Nursing progress documented: - on 5/1/2024 at 6:11 AM Registered Nurse #30 documented at 3:30 PM a certified nurse aide reported the resident had been walking around the unit all night. When the certified nurse aide finished their care with another resident, they found Resident #119 lying on their right side in the common area. They alerted the nurse and the resident got up and was walking around again. No injuries were observed, and the resident continued to walk the unit with staff supervision. - on 5/2/2024 at 4:04 PM, Registered Nurse Unit Manager #14 documented a follow up regarding the 5/1/2024 fall. The resident reopened a previous skin tear to the lateral left elbow. Nurse Practitioner # 35 was made aware that the resident was walking bent over. Vital signs were within normal limits and their abdomen was soft and non-tender. - on 5/6/2024 at 2:15 PM, Registered Nurse Unit Manager #14 documented the resident had an order for bladder, kidneys, and ureter x-rays, and an ultrasound (an imaging test) on the left and right side of the abdomen. - on 5/7/2024 at 8:17 PM, Licensed Practical Nurse Unit Manager #17 documented they were called to the unit as the resident fell in their room. The certified nurse aide (unidentified) was filling out paperwork and when they looked back the resident was on the floor. The on-call medical provider was notified and ordered an x-ray of the cervical spine (neck area). - on 5/8/2024 at 4:28 PM, Registered Nurse Unit Manager #14 documented the resident had a fall witnessed by ultrasound technician #43 (during a portable ultrasound at 6:00 AM). Their range of motion was at their baseline and neurological checks were intact. The resident reopened a left elbow skin tear. - on 5/8/2024 at 1:22 PM, Nurse Practitioner #35 documented they rounded with the resident who sustained a fall the previous night. The cervical spine x-ray results were within normal limits. The resident was doing well without signs of distress. The resident had been seen for abdominal pain. The ultrasound showed possible gallstones and medical was awaiting radiology's official results. At 4:03 PM, the radiology report was positive for gallstones and the resident was sent to the hospital. The 5/8/2024 hospital computed tomography (CT, imaging test) report documented there was an acute (recent) appearing mildly displaced left eighth posterior (back) rib fracture. There were more chronic appearing fractures of the right ribs 8-11. A 5/9/2024 at 1:22 AM Registered Nurse #30 progress note documented the resident returned from the hospital at 12:30 AM. Their computerized tomography scan revealed a broken left 8th rib and gallstones with no signs of infection. A 5/10/2024 at 2:30 PM, Nurse Practitioner #35 progress note documented the resident was seen for a follow up visit following a hospital visit for abdominal pain. It was determined the resident had a fractured rib and gallstones. There was no documented evidence that the facility investigated to determine how and when the resident sustained a fractured rib. During a telephone interview on 5/21/2024 at 4:32 PM Nurse Practitioner #35 stated they reviewed accident and incident reports with the interdisciplinary team during morning report. Resident #119 was exhibiting signs of abdominal pain and an ultrasound was ordered. The resident was assessed for abdominal pain and showed no signs of discomfort. They were sent to the hospital for gallstones and a scan at the hospital revealed gallstones and a fractured rib. It was a closed fracture, and it was hard to determine when it occurred. The resident did have frequent falls and they recently had a cervical spine x-ray that did not show the fractured rib so it must have occurred after that x-ray. During an interview on 5/21/2024 at 4:43 PM the Administrator stated accident and incident reports were started after an incident occurred. The report was reviewed with the interdisciplinary team during morning report. Resident #119 had a witnessed fall in their room after an ultrasound. They were sent to the hospital for abdominal pain and while there, their scan revealed they had a fractured rib. The team determined the fractured rib was a result of the 5/8/2024 witnessed fall. During an interview on 5/21/24 at 1:30 PM Registered Nurse Unit Manager #14 stated all accident and incident reports were reviewed by the interdisciplinary team in morning report. They were started once the incident occurred. Witnessed statements were obtained going back 3 shifts if an injury of unknown origin occurred. Resident #119 had a witnessed fall on 5/8/2024 and was sent out to the hospital for abdominal pain. During their hospital stay a fractured rib was identified. They had completed the accident and incident report for the witnessed fall prior to the resident being sent to the hospital and were not sure if an accident and incident report should have been started once the rib fracture was identified upon their return. The rib fracture was considered a new diagnosis at that time. 2) Resident #48 was admitted to the facility with diagnoses including Alzheimer's disease (a type of dementia) and repeated falls. The 8/30/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for bed mobility, transfers, and locomotion with a wheelchair, and had no falls since admission or the prior assessment. The comprehensive care plan initiated 1/6/2021 documented the resident had a potential for falls. Interventions included, tender mattress on the floor next to the bed as an extension of their bed, call bell was in reach and answered promptly, and bed was kept in the lowest position. The care plan documented actual falls on 1/13/2021 (updated 1/14/2021) and 3/1/2021 (updated 3/2/2021). There were no updated interventions or other documentation of actual falls after 3/2/2021. A 10/16/2023 at 10:22 PM Licensed Practical Nurse #41 progress note documented Resident #48 was found at shift change face down at their bedside. They had a knot on their forehead and bruising to their left wrist. The on-call registered nurse, nurse practitioner, and daughter were all made aware of the fall. The resident denied any pain and neurological checks were initiated per the nurse practitioner. There was no documented evidence the resident was assessed by a registered nurse after the fall. A 10/17/2023 at 11:11 AM Licensed Practical Nurse Unit Manager #17 progress note documented a referral to occupational therapy due to fall and the resident needed a new wheelchair. A 10/18/2023 at 1:51 PM Licensed Practical Nurse Unit Manager #17 progress note documented the resident was day 2 post fall and doing great, range of motion was within normal limits, and the resident had no complaints of pain. A physical therapy referral was placed for falls. On 5/20/2024 the Accident and Incident report from Resident #48's fall on 10/16/2023 was requested from the Administrator. There was no corresponding report received for the incident. There was no documented evidence that the facility investigated regarding the 10/16/2023 unwitnessed fall and noted injuries to rule out abuse or neglect. During an interview on 5/21/2024 at 1:26 PM the Administrator stated an accident and incident report could not be located for Resident #48's fall on 10/16/2023. They stated there was staff turnover and the previous Director of Nursing was very secretive. During an interview on 5/21/2024 at 1:27 PM Certified Nurse Aide #22 stated falls were reported to the licensed practical nurse, and they stayed with the resident until an evaluation was completed by the registered nurse. Vital signs were obtained by the licensed practical nurse after a fall and then statements were provided by staff. During an interview on 5/22/2024 at 10:07 AM Licensed Practical Nurse Unit Manager #17 stated they were notified after a fall. Staff stayed with the resident and a registered nurse completed an assessment. If the registered nurse was not on the premises, a virtual phone assessment was completed. The physician and the family were then notified, and physician orders were followed. Licensed Practical Nurse #41 no longer worked at the facility. They were not sure if Resident #48 had a fall in October 2023. After a fall, all staff provided statements and it was discussed in daily report, care plans were reviewed and updated as needed. An accident/ incident report was completed. It was important for follow up care and for 2-3 days after a fall and ensure neurological checks and vital signs were completed. Every fall should have an accident and incident report for clarification of what happened, so an underlying cause could be identified, infections could be treated, or equipment could be modified. During an interview on 5/22/2024 at 10:42 AM the Assistant Director of Nursing stated if a certified nurse aide found a resident on the floor, a staff member stayed with the resident and either they or another registered nurse was contacted to do a physical assessment. The provider and the family were then notified. Unwitnessed falls required neurological checks for 72 hours and an accident/ incident report was completed. If it was a fall during the day, the accident/ incident report was initiated by Licensed Practical Nurse Unit Manager #17. If a fall occurred during off hours, the nursing supervisor was notified would start the incident report and gather statements from staff. The next business day falls were reviewed during morning report with the clinical team, the Director of Nursing, and the Administrator. All falls required an accident and incident report and were important for tracking purposes and the investigation led to interventions that needed to be added. They could not recall if Resident #48 had a fall in October 2023. 10NYCRR 415.4(b)

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 observation, record review, and interviews during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 of resident (Resident #52) reviewed. Specifically, Resident #52 did not have resident-specific interventions for the use of an indwelling urinary catheter (a tube placed in the bladder to drain urine). Findings include: The facility policy, Foley Catheter Use dated 12/2017, documented specific guidelines for the use of foley catheters would be provided on all patients within the facility and a comprehensive resident centered care plan would be developed. Resident #52 had diagnoses including cerebral vascular accident with right side hemiplegia (stroke with right side paralysis) and an unspecified open wound to the buttock. The 3/30/2024 Minimum Data Set assessment (resident assessment tool) documented the resident had severe cognitive impairment, had an indwelling urinary catheter, and had 3 unstageable (full thickness tissue loss with a wound base is covered with dead tissue) pressure injuries. Physician orders documented: - 2/21/2024 insert a urinary catheter to prevent further maceration (softening of skin due to moisture) to buttocks and to facilitate healing. - 2/24/2024 change catheter bag every 2 weeks; may change urinary catheter if plugged, leaking, or out; may irrigate urinary catheter with 50 milliliters of normal saline every shift and as needed if plugged or leaking; record output each shift. A 2/23/2024 at 11:41 AM Licensed Practical Nurse Unit Manager #1 progress note documented a physician order to insert a urinary catheter to prevent further skin maceration. A catheter was inserted that morning and was draining yellow urine. The comprehensive care plan effective 12/1/2023 and reviewed on 2/29/2024, documented the resident had urinary incontinence. The comprehensive care plan did not include documentation of the use of a urinary catheter. The comprehensive care plan effective 4/23/2024 documented the resident had skin breakdown located on the sacrum (upper buttocks) and the right gluteal region (buttocks). Interventions did not include the use of a urinary catheter. The 5/20/2024 resident care instructions ([NAME]) did not document the use or care of a urinary catheter. During an observation on 5/16/2024 at 10:16 AM, the resident urinary collection bag was in a dignity bag. There was yellow urine with white sediment in the connection tubing. During an observation on 5/21/2024 at 10:30 AM, the resident's urinary collection bag was in a dignity bag. There was yellow urine with white sediment in the connection tubing. During an interview on 5/21/2024 at 11:38 AM Licensed Practical Nurse Manager #1 stated physicians wrote the orders for the insertion of a catheter. The order would come up as a task for the nurses to complete. That task should be signed for and documented by whomever placed the catheter or performed any of the related ordered interventions. They stated Resident #52 had a catheter because of wounds on their bottom. There was an order for routine catheter flushes to maintain patency impaired patency may have been a factor in the prior infection. They expected staff to report any changes in urine output, urine consistency, or urine characteristics and that the catheter was being changed as ordered. These should be included in the care plan. If they were not in the care plan or not followed up on, it could increase the risk for an infection. 10NYCRR 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview during the recertification and abbreviated (NY00320383 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for 1 of 6 residents (Resident #48) reviewed. Specifically, Resident #48 developed moisture associated skin damage (open areas resulting from moisture on the skin) on 2 occasions when incontinence care was not provided routinely or as planned. Findings include: The facility policy, Incontinent Product Usage/ Attends Briefs created 8/2014 documented residents were cared for incontinence with a program that promoted healthy skin and kept residents dry and comfortable, while their dignity was maintained, and their quality of life was improved. Incontinence briefs were checked frequently for wetness and changed when soiled. Any redness, rashes, or blisters were reported to the charge nurse and all residents were monitored per their care plan. The facility policy, Toileting Residents created 8/2015 documented the registered nurse indicated the time frames a resident was toileted on the personal care sheet. The time frame reflected the individual needs of the resident on a 2-4 hour basis and as needed during the night. This was recorded in the personal care record. The certified nurse aide initialed the correct space that indicated the time the resident was toileted. The facility policy, Wound Identification and Wound Rounds revised 11/6/2023 documented the facility identified, assessed, and managed residents with pressure injuries, skin alterations, impairments, or wounds in accordance with current standards of practice. For newly identified pressure injuries, skin alterations, impairments or wounds, the licensed nurse completed a head-to-toe skin evaluation. The registered nurse completed a skin assessment that included documentation of size, depth, and stage if applicable and appearance of the skin impairment. The licensed nurse notified the health care provider and obtained a treatment order. The wound nurse developed the care plan for the new skin impairment and included prevention interventions as necessary. The licensed nurse performed a weekly and as needed skin monitoring and documented their finding in the electronic medical record. Resident #48 had diagnoses including Alzheimer's disease (a type of dementia) and urinary incontinence. The 4/28/2024 Minimum Data Set Assessment (a health assessment tool) documented the resident had severely impaired cognition, was dependent on staff for toileting, hygiene, bed mobility and transfers with a mechanical lift, was a risk for pressure ulcers, had applications of ointments/ medications other than to feet, had a pressure reducing device for the bed and chair, and did not reject care. The comprehensive care plan initiated 1/6/2021 and reviewed 12/28/2023 documented the resident was at high risk for skin breakdown related to decreased mobility and incontinence. Interventions included incontinence care, certified nurse aide to report skin conditions daily during care and report any abnormalities to the nurse, maintain turn and position schedule every 2-4 hours, and use skin protectant/ barrier when performing perineal care (washing genital and rectal areas). The resident exhibited impaired long term and short-term memory, limited judgement, and safety awareness. Interventions included repeat/ rephrase as needed, give simple cues, and staff anticipated and met any unexpressed needs. The 10/1/2023 through 10/16/2023 certified nurse aide documentation of care provided contained no documentation the resident was provided with incontinence care on 11 of 16 dates (16 of 48 shifts). The 10/18/2023 Assistant Director of Nursing's progress note documented the resident had a 3.5 centimeter by 2 centimeter open area to the left buttock and a 3.5 centimeter by 2 centimeter open area to the right buttock that would be treated with ointment that removed dead tissue. The 10/2023 Treatment Administration Record documented: - Initially ordered on 1/3/2023, zinc cream to coccyx (tailbone) twice daily and as needed. - A new order on 10/18/2023, cleanse open areas on the left and right buttocks with normal saline, pat dry, and apply topical ointment once daily. The 10/19/2023 Licensed Practical Nurse Unit Manager #17's progress note documented a referral to the wound care center. The 10/27/2023 Physician #15 offsite wound care center's initial visit note documented an injury to the perineum (area between the rectum and the genitals) from shearing from the chair, and fecal incontinence. Treatment included: cushion to wheelchair, place resident on their side in bed part of the day/spend more time in bed than chair, turn and reposition every 2 hours, changing incontinence briefs, and zinc oxide treatment with a component that adheres to wet skin/for incontinence, sensitive areas to bilateral buttocks wounds daily. The 10/2023 Treatment Administration Record documented the collagenase (ointment that removes dead tissue) treatment to the resident's buttocks was discontinued on 10/28/2023. The 12/6/2023 Physician #15 offsite wound care center's visit note documented the continued recommended treatment of bilateral buttocks wounds was zinc oxide treatment with a component that adheres to wet skin/for incontinence. The 12/2023 Treatment Administration Record documented: - zinc oxide cream continued to the resident's coccyx twice daily and as needed. - a new order, dated 12/29/2023, zinc oxide treatment with a component that adheres to wet skin/for incontinence, sensitive areas to the left and right buttocks daily. From 10/27/2023 through 3/6/2024, the resident was seen by the outside wound care center. The 2/14/2024 offsite wound care center's visit note by Physician #15 documented no treatment changes but keep the resident off their right buttock. The 3/6/2024, Physician #15's note documented the resident no longer had wounds to the buttocks. The care instructions (used by direct care staff to provide care) documented the resident's incontinence brief was to be changed every 2 hours starting on 3/11/2024. The 5/1/2024 Physician #15 offsite wound care center's visit note documented the resident should be followed by the facility wound care team and could see the offsite wound care center for urgent needs. The 5/9/2024 and 5/16/2024 Nurse Practitioner #16's weekly wound round notes did not document any skin issues to the buttocks. The 5/2024 Treatment Administration Record documented: - zinc oxide cream continued to the coccyx twice daily and as needed. - zinc oxide treatment with a component that adheres to wet skin/for incontinence to the left and right buttocks daily. From 5/1/2024-5/19/2024 the certified nurse aide documentation did not include documented evidence the resident was provided with incontinence care for 17 of 19 days (32 shifts). Observations of Resident #48 included: - on 5/16/2024 at 10:21 AM, sitting in a medical positioning wheelchair in the common area of the unit and at 4:14 PM, sitting in the medical positioning wheelchair in the common area of the unit with a urine odor noted on the resident. - on 5/17/2024 at 8:33 AM and 12:53 PM, sitting in a medical positioning wheelchair in the dining room. At 1:13 PM, staff wheeled the resident to the common area and placed them in front of the television. The resident remained in a medical positioning wheelchair in front of the television until 3:01 PM. - on 5/20/2024 at 8:18 AM sitting in a medical positioning wheelchair in the dining room for breakfast. At 9:52 AM, the resident was brought to the common area and placed in front of the television. At 10:15 AM, they were taken to a hair appointment in the medical positioning wheelchair. At 11:03 AM, they returned from the hair appointment and was placed in front of the television in the common area. They remained in the common area until 11:49 AM when they were wheeled to their room for incontinence care. During an observation and interview on 5/20/2024 at 11:54 AM, Certified Nurse Aides #20 and #21, and Licensed Practical Nurse #18 provided incontinence care to the resident. The resident's incontinence brief was saturated with urine and was removed. The mechanical lift pad (used to transfer a resident with a mechanical lift) was soiled with many areas of dried fecal matter was removed and replaced. A reddened area approximately the size of a ping pong ball was noted to the medial right buttocks. Licensed Practical Nurse #18 stated this area was reported to them that morning by an unidentified certified nurse aide and they had not seen it yet. They stated the resident had a treatment of zinc ointment for prevention. They left the room to get the Assistant Director of Nursing. Licensed Practical Nurse #18 returned to the room with the Assistant Director of Nursing, who reported this area to the buttocks was new and this was moisture associated skin damage. The resident had moisture associated skin damage in the past that had resolved. Licensed Practical Nurse #18 applied the ordered zinc ointment to the resident's buttocks per the direction of the Assistant Director of Nursing. Nursing progress notes through 5/21/2024 did not include documentation of the presence of the new skin issue on the resident's buttock. During a continuous observation on 5/21/2024 from 8:49 AM until 2:22 PM, Resident #48 was not provided with incontinence care/toileting. At 8:49 AM, the resident was in their medical positioning wheelchair in the dining room for breakfast; at 9:39 AM, the resident was wheeled into the common area and placed in front of the television; at 11:40 AM, the resident was wheeled into the dining room; at 12:42 PM, the resident was wheeled to the common area in front of the television; and at 1:54 PM, the resident was wheeled to the music activity near the nursing station. During an interview on 5/21/2024 at 1:47 PM Certified Nurse Aide #22 stated they reported any new skin issues to the unit licensed practical nurse or Licensed Practical Nurse Unit Manager #17. It was important to report skin issues so the wound would not get worse or get infected. Residents were toileted every 2-4 hours whether they were continent or incontinent. Resident #48 was incontinent. They provided incontinence care to them before breakfast when they got them out of bed that morning around 7:30 AM. They had not provided incontinence care to Resident #48 since then because they were busy. Certified Nurse Aide #22 stated the resident was at risk for skin breakdown and used to have a sore on their buttocks that recently healed. It was important they were toileted frequently for urinary tract infection prevention, for dignity, and for prevention of skin breakdown. They stated it was also important to check incontinence regularly on Resident #48 because they could not advocate for themselves. During a telephone interview on 5/22/2024 at 8:48 AM the resident's representative (designated on the face sheet as the resident's emergency contact person) stated in 10/2023, they observed wounds on the resident's buttocks. At that time, they requested the resident go to the wound care clinic because they did not feel the facility monitored skin closely. The wound care clinic provided a cream for the resident's buttock wounds and the wounds cleared up. They were not aware of any current wounds to the buttocks. When they came to visit the resident, the resident was often sitting up in their chair. They stated they regularly requested incontinence care upon arrival because they could smell incontinence odors on the resident and the incontinence brief was normally saturated when it was changed. They stated they felt the resident was probably soiled all day, regularly. During an interview on 5/22/2024 at 9:46 AM Licensed Practical Nurse #19 stated if a new skin issue was reported to them, they would look at it and report it to Licensed Practical Nurse Unit Manger #17. Certified nurse aides were expected to look at the skin when care was provided. Residents were toileted every 2-4 hours and as needed. Incontinence care was important for dignity, illness/infection prevention, and good hygiene. If a resident was a risk for pressure ulcers, they should be provided with incontinence care closer to every 2 hours and turned and repositioned. If they were not, it could create pressure or make it worse. It was not appropriate for anyone to be in the same incontinence brief for 6-7 hours as it promoted skin breakdown. Resident #48 was incontinent and at risk for pressure ulcers and should be provided with incontinence care regularly. The resident was not able to tell staff if they were soiled. During an interview on 5/22/2024 at 10:07 AM Licensed Practical Nurse Unit Manager #17 stated when a new skin issue was reported to them, they let the Assistant Director of Nursing know and then the resident would be seen by Wound Nurse Practitioner #16. It was important the certified nurse aides reported new skin issues so they could be addressed and prevent infection. If they were not made aware of new skin issues, they could worsen. All residents were toileted or provided with incontinence care every 2-4 hours for urinary tract infection prevention and wound prevention. If Resident #48 was not provided with incontinence care, it could lead to pressure sores. They had been made aware of a new sore to the resident's buttocks and the resident seated in their chair for 6-7 hours without having their incontinence brief changed could have contributed to the new sore. During an interview on 5/22/2024 at 10:42 AM the Assistant Director of Nursing stated they rounded with Wound Nurse Practitioner #16 weekly. Resident #48 was incontinent and at risk for pressure ulcers. They stated they first noticed moisture associated skin damage to Resident #48 on 10/18/2023 and that had since resolved. The resident was supposed to be provided with incontinence care every 2-4 hours. If the resident was not provided with frequent incontinence care moisture associated skin damage could occur. The new sore from 5/20/2024 was also moisture associated skin damage. Certified nurse aides were expected to check skin with shower days and with daily care and report any abnormalities. Skin issues should be caught early if the resident's skin was checked every 2-4 hours when care was provided. Any new skin issues were reported to a nurse and then the Assistant Director of Nursing would assess the new area and place the resident on the list to be seen by the wound nurse practitioner and update the wound nurse practitioner of the new skin issue. The resident was scheduled to be seen again by wound Nurse Practitioner #16 on 5/23/2024 who would assess the moisture associated skin damage to their buttocks at that time. During an interview on 5/22/2024 at 2:08 PM, Wound Nurse Practitioner #16 stated they were not notified of a new skin issue with Resident #48. They stated if there was a new skin issue on an already established patient of theirs, they were notified of new skin issues when they rounded on Thursdays. They had started to care for Resident #48 a few weeks ago as the offsite wound center had deferred to onsite wound care. They stated they only looked at healed wound areas if a concern was brought to their attention. Moisture associated skin damage was exactly what the name implied. Interventions for prevention included barrier cream and incontinence care. If Resident #48 was soiled for 6-7 hours, it could cause moisture associated skin damage and could lead to pressure sores. Incontinence care should be provided per facility policy. 10NYCRR 415.12(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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview during the recertification and abbreviated (NY00320383 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not post daily, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, accessible to residents and visitors for 4 of 6 days reviewed. Specifically, the current daily resident census was not documented, and the licensed nurse staffing was not divided into licensed practical nurses and registered nurses for each shift in a 24-hour period. Findings include: The undated facility policy, Staffing Plan documented the facility provided 24-hour nursing services sufficient to meet the total nursing needs of the residents. Daily staffing sheets were completed by the night nursing supervisor and posted in the lobby. The daily resident census and nurse staffing information was observed posted to the right of the front receptionist desk: - on 5/16/2024 at 9:30 AM. - on 5/17/2024 at 8:28 AM. - on 5/20/2024 at 8:30 AM. - on 5/21/2024 at 8:30 AM. The posting did not include the daily census and did not include the total number and actual hours worked per shift for registered nurses, licensed practical nurses, and certified nurse aides that were responsible for resident care. During an interview on 5/21/2024 at 1:26 PM, the Administrator stated they were not aware the posted staffing should include separate shifts, and separate hours for the licensed staff. They were not aware the census was not listed on the current postings. They stated it was important and provided transparency to the residents and families of the type and quantity of care givers the facility provided to the residents. 10 NYCRR 415.13

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure planned menus were followed for 2 of 2 residents (Resident #23 and #117) reviewed. Specifically, Residents #117and #23 did not receive menu items as planned per their individual meal tickets. Findings include: The undated facility policy, Meal Delivery documented dietary staff were responsible to ensure that all items were placed on the meal tray as indicated on the meal ticket, including requested condiments. During an observation on 5/17/2024 at 1:23 PM, Resident #117's lunch tray was delivered to their room, used for a test tray, and a new tray was ordered for the resident. The original tray ticket documented the resident was to receive peppers, matzo ball soup, and gravy. None of these items were on Resident #117's tray. During an observation on 5/20/2024 at 12:38 PM, Resident #23's lunch tray was the last tray in the hot box brought from the kitchen. The resident's meal was used to for a test tray, and a new tray was ordered for the resident. The original tray ticket documented the resident was to receive a pineapple cup. The pineapple cup was not on Resident #23's tray. During an interview on 5/22/2024 at 9:26 AM, the Food Service Director stated in the main kitchen there was a dedicated staff member who checked the meal tickets (menus) during the food plating process and ensured all food items were on the resident trays. They stated prior to a resident tray being served, a nurse on the floor verified the food items on the ticket and the food items on the tray matched. The Food Service Director stated if there were missing food items staff should call the main kitchen for what was missing. They stated there had been some resident complaints in the past regarding missing food items, and they had completed test trays and audits. They stated there were no recent complaints about this issue. 10NYCRR 415.14(c)(1-3)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (lunch meals on 5/17/2024 and 5/20/2024) reviewed. Specifically, food was not served at palatable and appetizing temperatures for lunch on 5/17/2024 and 5/20/2024. Findings include: The undated facility policy Palatability documented hot food was served at no less than 140 degrees Fahrenheit after following proper cooking. Cold food was served at no higher than 40 degrees Fahrenheit after following proper procedure for portioning, holding, and storage. Carts were plugged in on the floors and maintained temperature during tray pass for each meal to maintain a meal temperature palatable to most residents. During an observation on 5/17/2024 at 1:23 PM, Resident #117's lunch meal tray was delivered to their room, used for a test tray, and a new tray was ordered for the resident. At 1:24 PM, the food temperatures on the tray were measured with the following results: the French fries were 91 degrees Fahrenheit, the ground fried chicken was 106 degrees Fahrenheit, the mixed vegetables were 106 degrees Fahrenheit, and the apple juice was 61 degrees Fahrenheit. The French fries, ground fried chicken, mixed vegetables, and the apple juice were not served at palatable temperatures. During an observation on 5/20/2024 at 12:38 PM, Resident #23's lunch meal tray was the last tray in hot box brought from the kitchen, used for a test tray, and a new tray was ordered for the resident. At 12:44 PM, using a kosher approved thermometer, the food temperatures on the tray were measured with the following results: the mashed potatoes were 117 degrees Fahrenheit, the soup was 108 degrees Fahrenheit, the beef stew was 106 degrees Fahrenheit, and the cabbage was 90 degrees Fahrenheit. The mashed potatoes, soup, beef stew, and cabbage were not served at palatable temperatures. During an interview on 5/22/2024 at 9:17 AM, the Food Service Director stated the food service management team did test trays a couple of times a week, and that three test trays and 14 audits food had been completed for April 2024. They stated residents had complained during resident council about cold food. Staff were told to keep the hot box doors closed when not being used and to keep the hot boxes plugged in. The Food Service Director stated that hot food was palatable at 115 degrees Fahrenheit to 135 degrees Fahrenheit depending on the individual resident preference. Cold food shelf stable items should be served at 40 degrees Fahrenheit to 50 degrees Fahrenheit. They stated the temperatures of the French fries, the ground fried chicken, the mixed vegetables, the apple juice, the soup, the beef stew, and the cabbage were not palatable temperatures. The Food Service Director stated it was important that all cold and hot food items were maintained at palatable temperatures. 10NYCRR 415.14(d)(1)(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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on record review, observation, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen, and 1 of 3 unit kitchenettes (Terrace unit kitchenette). Specifically, in the main kitchen the ventilation hood system was missing a grease trap, there were multiple stained ceiling tiles, there was a hole in one of the kitchen walls with exposed wiring, the meat side of the freezer floor was in disrepair, and there was expired and undated food; and the Terrace unit kitchenette had expired and undated food. Findings include: The facility policy, Guidelines for Receiving and Stock Rotation, revised 6/1/2022, documented the code date on products was noted: best before date, expiration date or use by date; and stock was rotated so that old stock was used before the new stock. The facility Daily Cleaning Schedule documented the meat side freezer was swept and mopped daily. The following was observed in the main kitchen on 5/16/2024, between 9:15 AM and 10:15 AM: - the dairy side cooler had 11 half pints of low-fat milk dated 5/15/2024, and two half pints of chocolate milk dated 5/14/2024; - the ventilation filters for the dairy side hood system were missing a grease trap; - near the dairy side three bay sink there was an 8 foot x 10 foot section of the ceiling that was stained with miscellaneous debris; - a wall in between the dairy side of the main kitchen and the meat side of the main kitchen had a one inch circular hole with exposed wires inside which could get wet when the wall was cleaned; - the dirty side of the dish machine had three stained 2 foot x 4 foot ceiling tiles; - the meat side blender area had two stained 2 foot x 4 foot ceiling tiles; - the meat side cooler had two 6 packs of poppyseed bagels, one 6 pack of plain bagels, and one 6 pack of sesame bagels that were not dated; - the floor in the meat side freezer had a section of flooring that was lifted, unsafe, and was a tripping hazard; - the meat side bread rack had loaves of bread dated 4/10/2024 and 5/7/2024, a sweet rye bread dated 5/10/2024, an undated marble rye bread, and an opened club wheat bread dated 4/17/2024. During an observation on 5/16/2024 at 9:37 AM, with the Food Service Director present, the Terrace unit kitchenette non-kosher refrigerator contained a half round cake that was dated 5/11/2024, an undated container of mashed potatoes, an undated container of chicken salad, a bag of moldy grapes, and a staff blue lunch box. During an interview on 5/22/2024 at 8:50 AM, the Food Service Director stated they were aware of a couple of the stained ceiling tiles in the kitchen. The ceiling tiles had not been cleaned in a few months. They could not verify that maintenance was made aware of the stained ceiling tiles. If a ceiling tile had to be replaced the kitchen staff contacted the maintenance department and it was replaced by a maintenance worker. The Food Service Director was not sure how long the wall had the hole in it, and stated there should be no holes in the lower walls as they were sprayed weekly. They stated they were not sure where the missing grease trap went or when it went missing. The diamond plate floor in the meat side freezer had been replaced three years ago, the height gap had gotten worse over time, and they were not sure if the current Maintenance Director was aware of this. A stock person was responsible to ensure milk was checked for expired dates three times a week. The stock person who worked on 5/14/2024 should have reported there was milk due to expire that day, as well the next day, and should have reported that to a manager. They stated on 4/18/2024, when the facility went into Passover, all the bread was thrown out and was not sure where the expired bread from April 2024 had come from. The Food Service Director stated the toast bread, and sweet rye loaf had come in expired during the most recent bread delivery. They verified that the bagels and marble rye loaf were not dated, and stated the expiration dates for this food was located on the original boxes these bread products were delivered in. The Food Service Director stated that all food items within the kitchen must have an expiration date, and it was important that the kitchen was maintained for the safety of residents and staff. 10NYCRR 415.14(h)

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure resident call systems were accessible to call for staff assistance for 2 of 2 residents (Residents #15 and #56) reviewed. Specifically, Resident #15 was observed with their call light out of reach, and Resident #56 was left alone in the shower room without access to the call light. Findings include: The facility policy, Call Light, revised 3/2024, documented all residents would have access to and know how to operate the facility call light system to ensure residents' physical and safety needs were met in a timely manner. 1) Resident #15 had diagnoses including amnesia (loss of memory), unspecified pain, and repeated falls. The 3/8/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, severely impaired vision, two falls, and required substantial/maximal assistance for all transfers. The comprehensive care plan dated 9/19/2023 documented Resident #15 was at risk for falls. Interventions included to ensure call light was within easy reach at all times. Resident #15 was observed at the following times: - on 5/16/2024 at 11:49 AM, sitting in their recliner. The call light was resting on the overbed table out of reach of the resident. - on 5/17/2024 at 8:37 AM, resting in bed. The call light was on the floor out of reach of the resident. - on 5/17/2024 at 12:31 PM, sitting in their recliner. The call light cord was clipped to the top right side of the recliner, but the button portion of the cord was laying on the floor out of reach of the resident. - on 5/20/2024 at 8:35 AM, resting in bed. The call light was on the floor out of reach of the resident. At 9:01 AM the resident was in their room and calling, Yoo Hoo, and Where are you? - on 5/20/2024 at 10:23 AM, sitting in their recliner listening to an audio book. The call light was on the floor out of reach of the resident. During an interview on 5/22/2024 at 8:49 AM Certified Nurse Aide #23 stated all call lights needed to be within arm's reach and when a call light was alarming, it had to be answered timely. If a resident could not reach the call light, they would not be able to ask for help, they might try to stand up without assistance, or they could fall and hurt themselves. Call lights should always be within reach even in the bathrooms. Resident #15 did not see well but was able to feel around for things and was able to use the call light effectively. They did not believe the resident had a history of falls or tried to get up unassisted. 2) Resident #56 had diagnoses including left femur fracture (broken thigh bone), dementia, and anxiety. The 2/3/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required maximal assistance for bed mobility, was dependent for transfers and toileting hygiene, was usually understood and could be understood. The comprehensive care plan initiated 6/14/2024 documented the resident had a communication deficit related to a hearing impairment. Interventions included to make certain the call light was within easy reach. During an observation on 5/20/2024 at 11:34 AM, Resident #56 was taken into the shower room and was placed on green plastic mesh shower stretcher. At 12:00 PM, Certified Nurse Aide #27 exited the shower room alone. At 12:12 PM (2 minutes later) Certified Nurse Aide #27 returned to the shower room but the door was locked. They went down the hall to get the nurse and then returned to the shower room door waiting for the nurse. When the nurse arrived 2 minutes later, the key did not work. The nurse went back down the hall to retrieve a different key. When they returned moments later, they were able to unlock the door. The resident was observed lying on their back in the shower stretcher. The shower stretcher was pushed up against the shower stall wall and the call light was at the foot of the stretcher, out of reach of the resident. During an interview on 5/20/24 at 2:00 PM Certified Nurse Aide #27 stated they typically did not leave a resident in the shower room alone but had difficulty getting the help they needed. The nurse was supposed to come to the shower room to perform wound care but did not show up. They were frustrated to be kept waiting, so they left the resident in the shower room while they went to retrieve the nurse. They were unsure how long they had left the resident alone, but stated it was a little while. They described Resident #56 as being stiff, unable to move by themself, and never attempting to get up by themself otherwise they would have never left the resident alone. They did not recall if they gave the resident the call light before they left the shower room. They thought about activating the shower room call light to get assistance so they would not have to leave the resident alone but did not think anyone would answer. They stated a resident should not be left alone on a shower stretcher as it could cause anxiety or a fall. During an interview on 5/22/2024 at 8:55 AM Licensed Practical Nurse Unit Manager #1 stated all call lights should be answered within 7-8 minutes and all staff was responsible for answering the call lights. No residents should be left alone without being able to reach their call light. Every resident on the unit should have access to a call light whether they were in their room, in the bathroom, or in the shower room. If call lights were not answered timely residents could fall and get hurt. 10NYCRR 415.29

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

Safe Environment (Tag F0584)

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, observation, and interview during the recertification survey and abbreviated (NY00311928 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (Terrace floor unit, first floor unit, and second floor unit) reviewed. Specifically, the Terrace floor unit had unclean resident wheelchairs, damaged and sticky flooring, and damaged countertops; the first floor unit had sticky floors in the dining room; and the second floor unit had a resident room with a damaged commode, a spa room with a water damaged cabinet, cigarettes and loose tobacco were kept in the second floor unit kitchenette, and the noise level in the dining room was loud during meal service. Additionally, the Terrace floor unit, first floor unit, and second floor unit had spa access doors that self-locked from the inside when opened too hard. Findings include: The facility policy, Safe, Clean, Homelike Environment revised 3/2024, documented all staff were responsible for the creation and maintenance of a clean, safe, homelike environment and a pleasant dining experience that promoted social interaction. 1) Unclean Resident Wheelchairs During observations on 5/16/2024 at 10:42 AM and 5/17/2024 at 1:03 PM, Resident #26 was in the Terrace unit lounge area seated in their positioning recliner chair. The chair had dried food debris on the footrest and the side of the chair. During observations on 5/16/2024 at 10:37 AM and 2:23 PM, 5/17/2024 at 8:53 AM and 1:13 PM, Resident #41 was observed seated in their wheelchair on the Terrace Unit. Their wheelchair was unclean with dried food debris on the frame. During an interview on 5/22/2024 at 10:05 AM, Licensed Practical Nurse Unit Manager #6 stated certified nurse aides on the 11:00 PM-7:00 AM shift were responsible to ensure resident wheelchairs were cleaned. If staff noticed the chairs were unclean on the resident's shower day, they should be cleaned. It was easier to clean the chairs on the night shifts as the residents were typically in bed. Unclean chairs were undignified and were a potential infection control issue. During an interview on 5/22/2024 at 10:27 AM, certified nurse aide #7 stated they were unsure if Resident #26's and Resident #41's chairs were unclean or stained because they appeared to be old. The 11:00 PM-7:00 AM shift was responsible to ensure the resident's chairs were clean. Anyone could clean a resident's chair if they noticed it was unclean. Unclean chairs were undignified and a possible infection control issue. During an interview on 5/22/2024 at 10:49 AM, the Director of Environmental Services stated nursing was responsible to ensure wheelchairs were cleaned. Wheelchairs were cleaned mostly during the third shift or during resident showers. They stated they did not notice any unclean wheelchairs during a recent walk through of the facility. 2) Loud Environment During an observation on 5/16/2024 at 2:07 PM, an unidentified dietary aide cleared trays and dishware from the tables in the second floor unit dining room. They picked up the dishware, scraped it off, and placed it in bins on a wheeled cart. This scraping and placement of the dishes in the bins caused a very loud clatter, and they continued to do this from table to table. There were seven residents in the dining room eating. At 2:13 PM, three residents remained in the dining room eating. The unidentified dietary aide began removing dishes from one of the tables a resident was eating at, and loudly scraped the food off the plates. During an observation on 5/17/2024 at 10:18 AM, the same unidentified dietary aide from the 5/16/2024 observation was in the second floor unit dining room. They moved from table to table and cleared dishes. Residents were still in the dining room eating at tables that were being cleared by the dietary aide. They scraped and then placed breakfast dishes in bins in a manner that caused loud clatter. They attempted to remove a tray of food that was in front of Resident #57 without asking if the resident was done eating. The resident leaned forward and said, no, no, no. The unidentified dietary aide then slid the tray back over to the resident. During an observation on 5/17/2024 at 1:21 PM, the second floor dining room had meal cart #2 plugged into the wall in the dining area between tables of the residents. The cart was very loud, and it was difficult to hear the residents or staff talking. At 1:23 PM, Certified Nurse Aide #12 stated this is very loud and closed the cart doors and said it was much quieter. At 1:25 PM, another unidentified staff member stated, that cart is too loud and unplugged the tray cart. During an observation and interview on 5/20/2024 at 8:55 AM, a loud beeping was heard coming from room [ROOM NUMBER]. Resident #44's tube feeding machine had completed the feeding and was beeping. The beeping continued until 9:41 AM (46 minutes later). Licensed Practical Nurse Unit Manager #1 entered the room and shut the tube feeding machine off. They stated the tube feeding ran for 12 hours and was started at 8:00 PM. They stated they should have shut off the tube feeding pump when it first started beeping but they were in the dining room assisting residents and could not be in two places at once. During an observation on 5/20/2024 at 10:22 AM, Licensed Practical Nurse #8 was assisting Resident #69 with their breakfast. An unidentified dietary aide was loudly dropping all the dishes from the table into the cart. They wiped the table down while the resident was still at the table being assisted with breakfast. During an interview on 5/22/2024 at 10:03 AM, Dietary Aide #4 stated they always tried to give the residents enough time to eat before the dining room was cleared and did not want to be in the way while the residents were eating. They stated the goal was to have the breakfast trays delivered to the unit by 9:00 AM, and the dining room was cleared no earlier than 10:00 AM, but sometimes things ran late. Dietary Aide #4 stated they sometimes had to clear trays while residents were still in the dining room because if they did not, it caused the next meal to be late. They stated if they had to clear while residents were still in the dining room, they started clearing on the side of the dining room that was served first, as those residents were typically done eating and already moved out of the dining room. They stated they would not clear from a table that a resident was still eating at as it would not be a nice or dignified experience for that resident. During an interview on 5/22/2024 at 9:49 AM, the Food Service Director stated the resident food hot boxes should be kept in the unit side hallways during use and should not be placed in the resident dining rooms. Once all residents were finished eating at a table staff cleared that table, even if residents at a table next to were still eating. They stated this had been the table clearing process for the last 17 years, and the Rabbi preferred a two hour window before the next meal due to kosher guidelines. The Food Service Director stated milk products and meat products could not be in the dining room at the same time, and that was why a table would be cleared immediately after all residents were done eating. During an interview on 5/22/2024 at 12:20 PM, the Administrator stated the warming units made some noise and they should be plugged in the unit 2 hall and not plugged in the dining room. 3) Unit Spa Self-Locking Doors During an observation on 5/20/2024 at 11:34 AM, Resident #56 was taken into the second floor shower room. At 12:00 PM, Certified Nurse Aide #27 exited the shower room alone. At 12:12 PM Certified Nurse Aide #27 returned to the shower room, but the door was locked, and the resident was inside. They went to get the nurse and returned to the shower room door and waited for the nurse. The nurse arrived moments later, and the key did not work. The nurse retrieved a different key and was able to unlock the door. During an observation on 5/20/2024 at 1:10 PM, the second floor spa room door locked from the inside when pushed open. If the door was pushed hard it opened into the room, and the push button door lock on doorknob inside the room was pressed, locking the door from the inside. On 5/20/2024, between 3:30 PM and 3:38 PM, the following was observed: - the first floor unit side spa door locked from the inside when pushed open. If the door was pushed hard it would open into the room, and the push button door lock on doorknob inside the room was pressed, locking the door from the inside. - the Terrace unit Lane side spa locked from the inside when pushed open. If the door was pushed hard it would open into the room, and the push button door lock on doorknob inside the room was pressed, locking the door from the inside. During an interview on 5/22/2024 at 10:54 AM, the Director of Environmental Services stated they were not aware the doors for the second floor spa, the first floor spa, and the Terrace unit lane side spa self-locked from the inside when the lock/unlock button hit the wall. They stated they had not heard of any residents being locked inside a facility spa room or staff needing to get a key to unlock the door. Those doors were original to the building. They stated maintenance of a safe environment for residents was important. 4) Unclean Floors/Ceiling Tiles/Resident care areas During observations on 5/16/2024 at 10:28 AM and 5/17/2024 at 8:36 AM, the first floor unit dining room floor was sticky. During observations on 5/16/2024 at 12:16 PM, 5/17/2024 at 8:36 AM, and 5/20/2024 at 9:31 AM, the Terrace unit dining room floor was sticky. There were several stained ceiling tiles throughout the dining room. On 5/16/2024, between 11:50 AM and 1:10 PM, the following was observed on the second floor: - resident room [ROOM NUMBER]'s bathroom had a commode with sections that were oxidized with bubbled paint. - the second floor unit lane side spa room cabinet had a section that was water damaged. - the second floor unit kitchenette had a staff food bag in the non-kosher refrigerator that contained loose tobacco and cigarettes. On 5/16/2024, between 12:41 PM and 1:00 PM, the following was observed on the Terrace floor unit: - the Terrace ridge unit side spa room had a section of floor with a missing tile, and a countertop that was chipped with exposed plywood. - resident room T17's floor was scraped with black marks. - the Terrace unit ridge side entrance to the dining room had a cabinet/sink with cracked drawers. During an interview on 5/17/2024 at 2:40 PM, the Director of Environmental Services stated all staff food bags should go in the staff break room. The second floor non-kosher refrigerator had a sign on it which read for residents only. They stated the second floor kitchenette was not where staff personal bags were stored. There should be no smoking material in the kitchenettes since family members and residents had access to these rooms. During an interview on 5/21/2024 at 1:24 PM, the Director of Environmental Services stated the dining room floors were mopped after every meal, a neutral floor cleaner was utilized, and they had never been told about sticky floors. The same floor cleaning chemical had been used for a few years. A daily task of the housekeeping staff was to clean the floors in the facility. They stated the commode in the bathroom of resident room [ROOM NUMBER] was in disrepair, and it did not look homelike and should have been replaced. Staff should have identified the commode and reported it to the maintenance department to be replaced. They were not aware of the cabinet with the damaged water section in the second floor lane side spa, or of the missing floor tile and the damaged countertop in the terrace ridge spa. These findings should have been identified by staff on the floor and reported to the maintenance department. The floor in resident room T17 floor was at the threshold to be stripped and waxed. They would usually complete this task when rooms were empty, but if a resident was living in the room they would be removed for a few hours and the room floor would be stripped and waxed. They were not aware the surface of the doors to the cabinet in the Terrace dining room were in disrepair and were not homelike. They would periodically tour the facility including sampling resident rooms and common areas. This was not documented. The Director of Environmental Services stated it was important a safe and clean environment for residents and staff was maintained. During an interview on 5/22/2024 at 11:09 AM, Housekeeper #5 stated the facility used a peroxide disinfectant on the laminated flooring for many years, and that it was a daily task for housekeeping to mop the floors in the dining room. They stated the dining room floors had been replaced a few years ago, and this new floor had a non-stick surface on it so staff and residents would not fall. Housekeeper #5 stated the dining room floors were mopped each day and certain spill spots on the floor required a more thorough mopping. They would try to buff and scrub resident room floors before they were too scraped up. They stated that if the scraping marks on a resident room floor had reached a certain threshold the floor would have to be stripped and waxed. Housekeeper #5 stated nursing staff was not unlocking the wheels on the resident beds before moving them. This created black dragging marks on the floor and was an ongoing issue. 10 NYCRR 415.29(c)(3-4)(d)(i)(3)(j)(1)

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 observation, record review, and interview during the recertification and abbreviated (NY00311928 and NY00320383) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 of 8 residents (Residents #31, #95 #103) reviewed. Specifically, Resident #31 was not assisted with showering, washing their hair, and removing facial hair; Resident #95 was not assisted with nail care; and Resident #103 was not assisted with toileting. Findings include: The facility policy, Physical Care/ADLs (activities of daily living) dated 11/2014, documented each morning and evening, the resident had attention to elimination, partial bathing, mouth care, hair combing, and dressing in clean clothing. Each resident had a minimum of one shower or tub bath per week and one bed bath per week. Nursing provided some choices in the bathing schedule. Each resident had an individualized plan for their hair care based on their wishes, and fingernails and toenails were kept clean and at the appropriate length. Male residents were shaved as often as necessary to keep them comfortable and neat, and females were free from facial hair unless they choose not to have the hair removed. The facility policy, Toileting Residents dated 8/2015 documented the registered nurse indicated time frames the resident should be toileted on the resident personal care sheet, and the time selected reflected the individual needs of the resident on a 2-4 hour basis and as needed during the night. This was recorded under the toileting section on the personal care record. After toileting, the certified nurse aide initialed in the correct space and indicated the time the resident was toileted. The certified nurse aide assignment sheet, resident care plan, and person care record reflected the resident's toileting approaches. 1) Resident #31 had diagnoses including dementia and cellulitis (skin infection) of the buttock. The 3/28/2024 Minimum Data Set assessment (health assessment tool) documented the resident had severe cognitive impairment, required substantial to maximal assistance with showering, and was dependent for personal hygiene. The comprehensive care plan last reviewed 12/27/2023 documented the resident required assistance with activities of daily living. Goals included the resident would be neat, clean, and well-groomed daily. Interventions included assistance of one staff for personal hygiene and toileting tasks, provide grooming needs, shower weekly per schedule, and shampoo hair with showers. The care instructions ([NAME]) last updated on 3/28/2024 documented the resident was dependent on staff for care and would have their shower on Mondays during the day shift. The resident was observed: - on 5/16/2024 at 10:38 AM, seated outside of their room in a reclining position chair. Their shoulder length hair appeared wet and greasy on the top and the back of their head. There were white flakes on their scalp. The resident had multiple ½ inch white gray hairs on their chin. The resident asked how many whiskers they had while trying to pull them out and stated, I have cat whiskers. - on 5/17/2024 at 9:36 AM, sitting in their reclining position chair. Their hair was greasy with white flakes on the scalp. The resident had multiple ½ inch white gray hairs on their chin. - on 5/20/2024 at 9:09 AM, lying in bed, dressed in grey pants and a long blue sleeve floral print shirt. Their hair appeared wet and greasy. The resident had multiple ½ inch white gray hairs on their chin. The certified nurse aide documentation for Resident #31 from 5/1/2024-5/20/2024 included: - on Monday 5/6/2024 there was no documentation care was provided. - on Monday 5/13/2024 a shower was documented as self-care. - on Monday 5/20/2024 there was no documentation a shower was provided. - on Tuesday 5/21/2024 and there was no care documented. During an interview on 5/21/2024 at 1:54 PM, Registered Nurse Unit Manager #14 stated staff reviewed the resident care plan for assistance level, shower days, and specifics for the resident. They had a shower schedule which matched the care plan and the tasks sheets. All resident care should be documented in the electronic medical record. If the care section was left blank, they could not determine that care was completed. If a resident refused care the aide should let the nurse know and then reapproach the resident. If the resident had refused showers they should have been notified. Personal hygiene included shaving of both men and women if they wished and should be done daily. Resident #31 had a history of refusals, but they were not made aware of any shower refusals. It was not dignified for women to have facial hair or greasy hair. They did notice the facial hair on Resident #31's chin. Every resident should be provided a shower and if they did not want one a note should have been written in the record why they did not receive a shower. If a shower was not provided a bath should be given instead so the resident felt clean. During an interview on 5/22/2024 at 9:50 AM, Licensed Practical Nurse Unit Manager #6 stated Resident #31 should have received daily care and that should have included removal of facial hair, washing their hair, and receiving their weekly showers. If a resident had dirty greasy hair, it was dignity issue and good hygiene was important for resident care. During an interview on 5/22/2024 at 10:12 AM, Certified Nurse Aide #7 stated they reviewed the care plan to find specifics for the resident's care including personal care needs and shower days. Personal hygiene consisted of oral care, facial care, cleaning, shaving men and women, and nail care. They stated they were responsible for Resident #31's care last week and the resident did not refuse care. They did not always have time to document the care they provided. They stated they did not give the resident a shower, wash the resident's hair, or remove the facial hair. They were aware of the resident's chin hair and should have shaved or trimmed it and completed the resident's shower. They stated the resident's hair was greasy and they should have washed the resident's hair even if it was not their shower day. They reviewed the documented care and stated it appeared the resident only received one shower in a month. 2) Resident #95 had diagnoses including Alzheimer's disease (a type of dementia) and hypertension (high blood pressure). The 3/2/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had severe cognitive impairment and required substantial to maximal assistance for personal hygiene. The 3/14/24 care instructions documented the resident required maximal assistance with bathing which included nail care, and their shower was scheduled on Thursday during the day shift. The certified nurse aide documentation documented the resident received a bath during the day shift on 5/16/24 but did not receive personal hygiene care on 5/2/24, 5/4/24, 5/7/24, 5/8/204, 5/9/2024, 5/10/24, and 5/12/24. During an observation on 5/16/2024 at 10:18 AM, the resident's fingernails were approximately 1/4 inch long and jagged, with a dark brown substance under all 5 nails on the right hand and under the left thumb nail. During an observation on 5/20/2024 at 10:41 AM, the resident's fingernails were long and jagged with dark brown debris under all 10 fingernails. During an interview on 5/21/2024 t 9:20 AM, Licensed Practical Nurse Unit Manager # 26 stated the resident's shower was scheduled for Thursdays during the day shift. During an observation on 5/21/2024 at 11:34 AM, the resident's fingernails were long with dark brown debris under all 10 fingernails. During an interview on 5/21/2024 at 1:54 PM, Registered Nurse Unit Manager #14 stated staff reviewed the resident care plan for assistance level, shower days, and specifics for the resident. All resident care should be documented in the electronic medical record. If the care section was left blank, they could not determine that care was completed. Personal hygiene included ensuring nails were clean, trimmed and filed. During an interview on 5/22/2024 at 9:50 AM, Licensed Practical Nurse Unit Manager #6 stated staff should review the care task sheet (care instructions) that was generated from the care plan for the resident's activity daily living care. This included shower day and any specific cares for the resident. Personal hygiene consisted of nail care (clean and trimmed). Resident #95 was not diabetic, and the aides should have completed the residents nail care. They stated it was important to keep nails clean and short as it was a dignity issue and infection control issue as bacteria could pool under the nail beds. During an interview on 5/22/2024 at 10:08 AM, Certified Nurse Aide #7 stated the resident did not refuse care and they had not noticed the resident's nails were dirty or they would have cleaned them. They stated the resident's nails should be clean and kept short to prevent them from scratching themselves and to keep bacteria from underneath the nails. They stated the certified nurse aide documentation indicated the resident received one shower in May. They stated based on the lack of documentation it appeared the resident did not receive showers on their shower days. It was important to document care otherwise it looked like the care was not complete. 3) Resident #103 had diagnoses including dementia, urge incontinence (an urgent and uncontrollable need to urinate), and a history of urinary tract infections. The 2/18/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had severely impaired cognition, did not reject care, was dependent for toileting, was frequently incontinent of urine and always incontinent of bowel. The comprehensive care plan reviewed 11/16/2023 documented the resident had an activity of daily living deficit. Interventions included assistance with toileting, brief/pad changes, and toilet before all meals. The resident was incontinent of bladder and would be maintained on a toileting program that promoted dignity and prevented skin breakdown. Interventions included redness and skin breakdown were monitored during toileting/ brief changed every 2-4 hours and as needed, and maintain toileting schedule every 2-4 hours and as needed. The May 2024 certified nurse aide documentation for Resident #103 did not document toileting was completed: - on 5/16/2024-5/17/2024 on the day, evening, or night shifts. - on 5/18/2024 and 5/19/2024 on the evening shift. - on 5/20/2024 on the day, evening, or night shifts. The following continuous observation of Resident #103 was made on 5/21/2024 from 8:49 AM to 2:22 PM: - at 8:49 AM sitting in their reclining position chair being assisted with breakfast. - at 9:39 AM, being wheeled to the common pod area in reclining position chair. - at 11:37 AM, being wheeled into the dining room. - at 12:33 PM being wheeled to the common area. - at 1:36 PM being wheeled to the music activity by the nursing station. - at 2:22 PM at the music activity sitting in their reclining position chair. Resident #103 was not provided with toileting/ incontinence care during this time. During an interview on 5/21/2024 at 1:47 PM Certified Nurse Aide #22 stated all residents were toileted every 2-4 hours whether they were continent or incontinent. Toileting was important for urinary tract prevention, and it prevented skin breakdown. Resident #103 was incontinent. They thought they toileted the resident around 9:00 AM but had not toileted them since 9:00 AM because they were busy. They stated the resident should be toileted frequently because they could not speak for themselves. During an interview on 5/22/2024 at 9:46 AM Licensed Practical Nurse #19 stated residents were toileted every 2-4 hours and as needed. Incontinence care was important for dignity, illness and infection prevention and good hygiene. It was not appropriate for anyone to be in the same incontinence brief for 6-7 hours as it promoted skin breakdown. Resident #103 sometimes verbalized they needed to use the bathroom but should still be toileted regularly. During an interview on 5/22/2024 at 10:07 AM Licensed Practical Nurse Unit Manager #17 stated all residents were toileted or provided with incontinence care every 2-4 hours for urinary tract infection prevention and wound prevention. It was not appropriate for any resident to be in the same incontinence brief for 6-7 hours and Resident #103 should have been offered to be toileted. 10NYCRR 415.12(a)(3)

CONCERN (E)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interviews during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 4 of 4 residents (Residents #26, #41, #109 and #119) reviewed. Specifically, Residents #26, #41, #109 and #119 were not offered meaningful activities of their choosing as care planned. Findings include: The facility policy, Activity revised 3/2024, documented the activity department would provide an organized and ongoing program for the residents. The program would meet the interests, physical, mental, and psychosocial well-being for reach resident. The activity programs would be developed in accordance to meet resident specific and individual needs/interests. All residents would be encouraged, reminded, and assisted to be involved no matter their level of ability. Each resident's monthly participation would be tracked by the activity aides. The facility policy Sensory Stimulation dated 4/2024 documented the activity department would provide group or individual sensory stimulation for those residents who may exhibit cognitive deficits, confusion, or disorientation. Sensory stimulation was the activation of one or more of the senses such as taste, sight, hearing, smell, and touch. Sensory stimulation was a key component for improving the quality of life for those living with dementia. Types of visits/ programs may include, but were not limited to music appreciation group, programs, or individual listening, and walking or wheeling outside. The May 2024 Terrace Recreation Calendar documented on 5/16/2024 at 2:00 PM there was a live Elvis concert outside under the tent. During an observation on 5/16/24 at 10:37 AM, a sign posted in the elevator documented there was an outdoor Elvis concert under the tent out front of the facility at 2:00 PM and popcorn and cotton candy would be served. 1)Resident #41 had diagnoses including Alzheimer's disease (a type of dementia), major depressive disorder, and generalized anxiety disorder. The 7/6/2023 Minimum Data Set Assessment (a health status assessment tool) documented the resident had severely impaired cognition, it was very important to the resident to listen to music they liked, to be around other people, to do their favorite activities, and go outside to get fresh air when the weather was good. The 6/29/2023 comprehensive care plan documented the resident was admitted to the facility for long term care. Interventions included to encourage the resident to participate in activities of choice. The resident required assistance of 1 with all aspects of care including transfers and ambulation. The resident ambulated with a rolling walker and staff assistance or wheelchair with staff assistance. The 7/10/2023 activities comprehensive care plan documented to provide and review the program calendar to help identify activities of interest, respect refusal, and re-approach. The resident liked music. A 1/4/2024 Director of Activities progress note documented the resident was able to voice their leisure interests to staff when asked or promoted. The resident needed staff to encourage them and bring them to groups. They liked to be around others, would attend live music, singalongs, and socials. Recreation staff would continue to invite them to attend groups. The 4/3/2024 activities quarterly assessment completed by activity aide #39 documented the resident's hearing was adequate and they participated in group activities both large and small. The resident needed reminders, encouragement, and cuing/redirection. Their activity preferences included entertainment/music, social hours, and outdoors. The resident needed staff to encourage them and bring them to groups. The resident enjoyed being around others, and attending live music and singalongs. Recreation staff was to continue to invite them to attend groups. During an observation on 5/16/24 at 2:20 PM, Resident #41 was inside on the unit and asked, What do we do now?. The resident stated they would love to go outside. Resident #41's May 2024 activity log did not document they had gone outside or attended live music entertainment on 5/16/2024. 2) Resident #109 had diagnosis including Parkinson's disease (a progressive neurological disorder) and Alzheimer's disease (a form of dementia). The 5/19/2023 Minimum Data Set Assessment documented the resident had severely impaired cognition, the resident felt it was very important for them to listen to music they liked, somewhat important to do things with groups of people, very important to attend favorite activities, and to go outside to get fresh air when the weather was good. The 5/13/2023 comprehensive care plan documented the resident had cognitive deficits and staff would anticipate and meet the resident's needs and speak slowly and clearly, allowing the resident adequate time to process information. The resident required assistance with all aspects of care and was non-ambulatory. The resident required assistance with wheelchair mobility. The updated 5/22/2023 activities comprehensive care plan documented to provide and review the program calendar with the resident to help identify activities of interest and respect refusal and re-approach. The resident liked music. A 5/13/2024 Director of Activities progress note documented the resident could answer simple questions. They joined groups but required redirection and cueing. The resident enjoyed attending live music. The resident also would people watch. Recreation staff was to continue to invite and encourage them to attend groups of interest. The 5/13/2024 activities annual assessment completed by the Director of Activities documented the resident had normal hearing, semi-actively participated in activities, needed encouragement, cueing, and transportation. The resident enjoyed entertainment/music and social hours. On 5/16/2024 at 2:39 PM, the resident was observed seated in their chair in the television lounge on the unit. At 2:43 PM, the television signal went out. Resident #109's May 2024 activity log did not document they had gone outside or attended live music entertainment on 5/16/2024. 3) Resident #119 had diagnoses including Parkinson's disease (a progressive neurologial disorder) and neurocognitive disorder with Lewy bodies (a type of dementia). The 10/13/2023 Minimum Data Set Assessment documented the resident had severely impaired cognition, enjoyed listening to music, doing things with groups of people, and participating in favorite activities. The 10/6/2023 comprehensive care plan documented the resident was admitted to the facility for long term care. Interventions included to encourage the resident to participate in activities of choice. The resident had cognitive deficits related to their diagnoses and exhibited impaired long term and short memory loss. Interventions included to speak slowly and clearly, allowing the resident adequate time to process information. The resident required assistance with all aspects of care and was independent with mobility. The revised 1/17/2024 activities care plan documented the resident participated in live music and the outdoors. Interventions included provide and review program calendar to help identify activities of interest, respect refusal and re-approach. A 1/17/2024 Director of Activities progress note documented the resident was able to voice their leisure interests when prompted and would occasionally join group activities such as live music, or sometimes would sit in the main areas of the unit and people watch. Recreation staff would continue to encourage them to join groups. The 4/22/2024 Activities quarterly assessment completed by the Director of Activities documented the resident's hearing was normal, they participated in group and individual groups, were a semi-active participant, required encouragement, liked entertainment/music, and outdoors. The resident needed staff to invite them and encourage them to attend groups. They liked attending live music and getting outside. Recreation staff was to continue to invite and encourage them to attend groups of interest. A 5/9/2024 Director of Activities progress note documented the resident had a short attention span, enjoyed musical activities, and socializing with others. During an observation on 5/16/24 at 2:40 PM, the resident was observed seated in a chair on the unit watching television. During an interview with the resident's representative on 5/16/2024 at 3:45 PM, they stated the resident loved music and was a musician. Resident #109's May 2024 activity log did not document they had gone outside or attended live music entertainment on 5/16/2024. During an interview on 5/22/2024 at 10:38 AM activity aide #39 stated the Terrace unit was a locked unit and most of the residents had dementia. The Director of Activities came up with the activity calendar along with resident unput. The facility celebrated National Nursing Home Week the prior week. They had special events planned for the week including a live Elvis concert outside under a tent in the front of the building. The activity staff collaborated and came up with a list of residents they determined who would not be appropriate to attend the day of the event. They thought the Director of Activities had a copy of the list. Resident preferences were obtained on admission, annually, and during quarterly assessments by interviewing the residents or resident representatives. It was important for the residents to attend activities of interest for stimulation, quality of life, and enjoyment. Activity staff only documented if the residents attended activities and did not document if they refused to attend events. They were unsure why Resident #119 did not attend the live music event. They stated Resident #41 was asked to attend the event but declined. Resident #109 liked music and going outside, they thought the resident was sleeping in their chair when residents were brought outside. They stated they should have woken Resident #109 up and asked them if they wanted to attend the event. During an interview on 5/22/2024 at 11:04 AM the Activities Director stated the department decided which programs to put on the calendar with the resident's input. The activity staff completed the resident's assessments and obtained their activity preferences on admission, annually, and quarterly via interviews with the resident or their representative. Activities were important for the resident's quality of life and wellbeing. The Terrace Unit was a memory care unit. The Elvis concert was opened to all residents to attend. They did not have list of residents to ask to the event and expected staff to invite all residents as this was a special event for National Nursing Home Week. They had been discussing the event in the facility's morning report for some time and the need for all hands-on deck approach to transport residents. They wanted as many residents as possible to attend the event. They were unsure why the turnout was not as large as they expected, but it was tough getting the residents out with the limited staff they had. They stated they were working with the activity staff to improve their documentation as they did not document refusals at this time. Any resident who enjoyed music and being outdoors should have been offered to attend the activity. 10NYCRR 415.5(f)(1)

CONCERN (E)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, did not review the risks and benefits of bed rails with the resident or resident representative, and did not obtain informed consent prior to the installation of bed rails for 4 of 4 residents (Resident #48, #59, #109, and #119) reviewed. Specifically: - Resident #109 had no documented evidence of a bed rail assessment prior to bed rail installation, explanation of the risks and benefits of bed rails to the resident or their representative, or consent prior to bed rail installation. Additionally, the resident's enabler bar was not removed timely, and the resident was found with their arm between the enabler bar and the mattress. - Residents #48, #59 and #119 had no documented evidence of a bed rail assessment prior to bed rail installation, explanation of the risks and benefits of bed rails to the resident or their representative, or consent prior to bed rail installation. Findings include: The undated facility policy, Use of Bed Enablers documented the use of bed enablers would be carefully considered and justified based on individual resident needs. Therapy would complete an assessment on admission and upon receiving a therapy evaluation from nursing. Careful attention for risk factors such as fall risk, mobility, cognitive status, and individual preferences would be taken into consideration before implementing. Therapy would send a work order to maintenance for the application of the bed enabler(s) per manufacturer instructions. Nursing staff would be responsible for documentation and care planning the use of the enabler device(s) and adding the information to the certified nurse aide care assignment sheet. 1) Resident #59 had diagnoses including spinal stenosis (spaces between the bones of the spine are narrowed) of the thoracic (mid back) region and chronic pain. The 4/26/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, functional limitation in both legs, required substantial/maximal assistance with rolling left to right, and was dependent for sit to lying and chair to bed transfers. The resident had falls prior to admission. The 3/20/2024 comprehensive care plan documented the resident was at risk for falls. Interventions included answer call bell promptly, keep call bell within reach, and mattress next to bed. On 5/8/2024 the resident was at risk for skin breakdown and interventions included to provide left and right bed enabler bars to assist with positioning and comfort. The 4/7/2024 Fall Risk Assessment documented the resident was at high risk for falls. On 4/8/2024 at 9:44 AM, the Director of Therapy sent an electronic mail to the Director of Nursing regarding the residents who needed or had bed enabler devices and were safe/ appropriate for use and Resident #59 was not included. During observations on 5/16/24 at 12:18 PM and 5/17/24 at 8:44 AM there were 1/4 bed rails on both sides of the resident's bed. There was no documented evidence of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. During an interview on 5/21/2024 at 11:01 AM Certified Nurse Aide #32 stated that Resident #59 had bed enabler bars on both sides of their bed, and they used them for positioning. The resident had a safety mat on the floor and had falls in the past. The bed enabler bars were not listed on the certified nurse aide assignment sheet. During an interview on 5/21/2024 at 12:35 PM the Director of Therapy stated the resident was able to use the bed enabler devices for positioning and was care planned for their use. The enabler bars could be a possible safety risk if the resident did not use them correctly. They did not review the risks or benefits with the resident's representative and did not obtain informed consent prior to installation of the enabler bars. 2) Resident #119 had diagnosis including Parkinson's disease (a progressive neurological disorder), neurocognitive disorder with Lewy body dementia, and repeated falls. The 1/23/2024 Minimum Data Set Assessment documented the resident had severely impaired cognition, had functional limitation of one arm, required supervision or touching assistance with rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, and chair to bed transfers. The resident had 2 falls without injury and 2 falls with injuries (expect major injuries) since admission/entry or reentry or the prior assessment and did not use any restraints or alarms. The 10/6/2023 comprehensive care plan documented the resident had cognitive deficits related to Lewy body dementia and had impaired long term and short-term memory, limited judgement, and safety awareness. The resident required assistance with all aspects with care. The resident required assistance with bed mobility and transferred with staff assistance. The resident was at risk for falls related to their cognitive deficits. Interventions included use appropriate devices and level of assistance as recommended. The resident was at risk for skin breakdown and the updated 5/8/2024 interventions included to provide a left side bed enabler device to assist with positioning and comfort. The 3/24/2024 Fall Risk Assessment documented the resident was a high risk for falls. During an observation on 5/16/24 at 10:12 AM the resident was in their room in bed. There was a 1/4 bed rail on the right side of the bed. There was bruise on the resident's right arm just above elbow. The updated 5/22/2024 certified nurse aide assignment sheet documented the resident was independent with bed mobility. It did not include the use of an enabler bar. There was no documented evidence of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. During an interview on 5/21/2024 at 12:56 PM the Director of Therapy stated the resident could use the bed enabler device. The enabler bars could be a possible safety risk if the resident could not use them correctly. They did not review the risks or benefits with the resident's representative and did not obtain informed consent prior to installation. 3) Resident #109 had diagnoses including Parkinson's disease (a progressive neurological disorder), Alzheimer's disease (a type of dementia), and repeated falls. The 2/17/2024 Minimum Data Set Assessment documented the resident had severely impaired cognition, rejected care 1- 3 days, and wandered 1- 3 days. The resident had functional limitation of both legs, was dependent for rolling left to right, lying on the side of the bed, sit to stand, and chair/ bed to chair transfers, had 2 or more falls since admission/entry or reentry or prior assessment with no injury, and used both a bed and chair alarm daily. The 5/12/2023 comprehensive care plan documented the resident had impaired short and long-term memory, limited judgement and safety awareness related to Parkinson's Disease and Alzheimer's Dementia. The resident had a vision deficit related to the aging process and cognitive deficits. The resident had an activity of daily living deficit and required assistance with all aspects of care including bed mobility assistance of 2, transfer assistance of 2, and was non ambulatory. The resident was at risk for falls and interventions included the use appropriate assistive devices and level of assistance as recommended. The care plan did not include the use of a bed enabler device. The 3/29/2024 certified nurse aide assignment sheet did not include the use of enabler bars. On 4/1/24024 at 8:58 AM, the Director of Therapy sent an electronic mail to the Maintenance Director with a list of residents that needed their bed enabler bars removed, Resident #109 was on the list. There was no documented evidence in the resident's record of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. The facility's 4/8/2024 Accident and Incident report documented to refer to the 4/9/2024 progress note completed by Registered Nurse Supervisor #30. Staff statements included: - Licensed Practical Nurse #31's statement documented the time of the incident was the first time they saw the resident that evening (at 11:50 PM). The care plan was followed, and the resident leaned a lot and was shaky due to Parkinson's Disease. The certified nurse aides found the resident lying half on and half off their bed with their head on the bed and feet/ legs on the mattress on the floor. The resident's right arm was pressed against the metal railing of the bed and a skin tear was found on their left arm. - Certified nurse aide #32's statement documented they did not see the resident until they found them. At the time of the incident, they were completing their rounds, the care plan was followed, the resident usually reaches for things, there was no change in their activity of daily living functions, and it looked like they were in that position for hours. - Certified nurse aide #33's statement documented they last saw the resident at the start of their shift during rounds in the resident's room. The resident was observed to be leaning off the bed with their head on the bed and their arm was wedged between the (bed) rail and the mattress. The resident's legs were on the mattress on the floor. The care plan was followed. The resident was known to get up and climb out of their bed. The resident had a cut on their left arm and their right arm was discolored from being wedged. On 4/9/2024 at 11:50 PM Registered Nurse Supervisor #30 documented on 4/8/2024 at 11:30 PM, the resident was found lying halfway out of their bed. Their upper torso was on the bed and their lower extremities were on the floor mattress. Staff reported their right arm was pressed against the bed and the enabler bar on the outside of the bed. The right arm was reported by staff as cold but at the time of the assessment the arm was warm to the touch with normal capillary refill. The care plan was followed and there were no apparent injuries noted. The provider would be notified in the morning and family was notified. A new order was obtained to initiate fall protocol and monitoring. No signs of abuse, neglect or mistreatment were identified, and nursing would continue to monitor. There was no documented evidence the enabler bar usage was reviewed after the incident despite therapy's request for removal on 4/1/2024. During an interview on 5/21/24 at 12:28 PM the Director of Therapy stated the therapy department determined if a resident needed enabler devices for positioning on their bed. The residents were evaluated for bed positioning upon admission and when they were receiving therapy services. If a resident was physically able to use the enabler device, therapy would send an electronic mail to the maintenance department who then installed the device. Therapy staff also determined if the devices were no longer needed. In the past both nursing staff and the therapy department reviewed the risks and benefits of bed rails with the resident or resident representative. They were unsure who obtained informed consent prior to the installation of the enabler devices. They thought the nursing staff added the enabler devices to the care plan. They stated on 4/1/2024 they completed a full house audit on residents who had enabler devices on their beds and requested that Resident #109's be removed as the resident was unable to follow commands and it was not safe. The resident was cognitively impaired, and it posed a possible safety risk. The Maintenance Director was notified via electronic mail of the request for removal. They were unaware the enabler device was still installed on the bed on 4/8/2024. During an interview on 5/17/2024 at 1:11 PM Registered Nurse Unit Manager #14 stated they thought nursing staff monitored the resident's ability to use the enabler devices installed on their bed. They were unsure who reviewed the risks and benefits of bed rails with the resident or resident representative. They were unsure who obtained informed consent prior to the installation of the enabler devices. They stated only residents who were able to use the enabler devices had them installed on their beds. Therapy recommended the use and discontinuation of the enabler devices and the maintenance staff installed and removed the devices. Resident #109 no longer had an enabler device installed on their bed and they were unsure if the resident was ever care planned for the use of the enabler device on their bed. They did not recall the 4/8/2024 incident when the resident was found with their arm between the enabler device and their mattress. They stated incident reports were reviewed by the interdisciplinary team during the report and the team reviewed care plan interventions. They stated enabler bed devices posed a possible safety risk for entrapment. During an interview with the Director of Maintenance on 5/21/2024 at 2:04 PM, they stated the therapy department notified them of which resident needed bed enabler devices installed or removed via electronic mail. They stated they received an electronic mail notification that documented Resident #109 needed their bed enabler devices removed on 4/1/2024 at 8:58 AM and again on 4/11/2024 at 3:10 PM. The bed enabler device should have been removed on 4/1/2024, but they did not have documented evidence the bed enabler device was removed until after the 4/11/2024 notification. Bed enabler devices posed a risk for injury, and it was important to remove the requested equipment for safety reasons. The facility checked the bed enabler devices during their monthly audits. During an interview on 5/21/2024 at 4:06 PM the Assistant Director of Nursing stated the therapy department determined if a resident could benefit from the use of a bed enabler device. Maintenance staff installed the device on the bed. They were unsure who reviewed the risks and benefits of bed rails with the resident or resident representative. They were unsure who obtained informed consent prior to the installation of the enabler devices. Nursing staff was responsible for updating the care plan if a resident used bed enabler devices and nursing or therapy could request the removal of the device. Nursing staff received notification on the installation and removal of bed enabler devices and therapy was responsible to ensure the devices were removed. They recalled the 4/8/2024 incident when Resident #109's arm was found pressed against their bed enabler device and mattress. They stated a request was made for the device to be removed and it was not done. If therapy determined the resident no longer could use the bed enabler device, it was a safety risk for the resident. During a telephone interview on 5/22/2024 at 1:22 PM Certified Nurse Aide #33 stated on 4/8/2024 they were completing their first rounds of the shift with another certified nurse aide. They observed the resident half on and half off their bed with their arm between the bed enabler device and mattress. They moved the resident's arm prior to the nursing supervisor coming to assess to the resident. They told the nursing supervisor what they saw when they found the resident and wrote a statement. They thought bed enabler devices were care planned but could not recall if Resident #109 had a bed enabler device on their care plan. 10NYCRR 415.12(h)(1)(2)

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 3 medication carts (second floor Ridge cart), and 1 of 2 medication rooms (first floor) reviewed. Specifically, the second floor Ridge medication cart was unlocked and unattended; and the first floor medication room had 3 bottles of alcoholic beverages stored in a brown paper box on the floor. Findings include: The facility policy, Medication Storage Policy last revised 4/2024, documented all drugs would be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. The facility policy, Medication Administration last revised 10/11/2023 documented the medication carts were to always be locked when not in use for medication administration; and locked and stored in a non-resident area on the unit when not in use for medication administration passes. The facility policy Resident Use of Alcoholic Beverages created 4/2011 documented residents who wished to consume alcoholic beverages on premises would have an order for use of alcoholic beverages by the attending physician or nurse practitioner. Medication Carts: During an observation on 5/17/2024 at 8:38 AM, a medication cart located on the second floor Ridge hallway was left unlocked and unattended for two minutes. There was no nurse in sight. During an observation on 5/17/2024 at 2:48 PM, an unattended, unlocked medication cart was in the hallway of second floor Ridge unit. There were no nurses in sight. During observation on 5/20/2024 at 8:35 AM, an unattended, unlocked medication cart was in the hallway outside the dining room of the second floor Ridge unit. Licensed Practical Nurse #3 returned to medication cart briefly, then left the cart unlocked to administer medications to a resident who was in the dining room. During an interview on 5/20/2024 at 9:12 AM, Licensed Practical Nurse #3 stated medication carts should be locked, and the computer screens should be closed anytime they walked away from the cart or turned their back to the cart. It was important to do this as staff, residents, or visitors could get into their cart and take something. If someone were to take a medication it could cause harm or illness. They were aware they had left the cart unattended and unlocked. They were pulled away from what they were doing by staff and residents. During an observation and interview on 5/20/2024 at 11:13 AM, Licensed Practical Nurse #8 unlocked the medication cart that was located outside of room [ROOM NUMBER] on the second floor Ridge unit, walked away, entered the dirty utility room, and then returned to the medication cart. Licensed Practical Nurse #8 stated the medication cart was supposed to be locked when not in their vision. The medication cart should be always locked when not in use to keep the medications safe and ensure the residents did not take any medicine they should not have. During an interview on 5/22/2024 at 8:55 AM, Licensed Practical Nurse Manager #1 stated all medication carts should be locked and tethered when the nurse was not physically going through the cart. It was important medication carts were locked so others did not remove and take any medications. This could cause harm or illness to someone. Medication room with Alcoholic Beverages: During an observation of the unit one medication storage room on 5/20/2024 at 3:38 PM with Licensed Practical Nurse #24, there was a cardboard box on the floor with a half empty 750 milliliter bottle of chardonnay wine labeled with Resident #75's name; an unopened, unlabeled 750 milliliter bottle of cabernet wine; and an unlabeled half empty 1750 milliliter bottle of brandy. Licensed Practical Nurse #24 stated they did not think the alcohol should be stored on the floor, but it had been stored there for the year that they had been employed at the facility. All alcohol should be labeled with the resident's name. During an interview on 5/22/2024 at 10:07 AM, Licensed Practical Nurse Unit Manager #17 stated residents could have alcohol if they had an order for it. All alcohol bottles should be labeled just like a medication. Resident #75 had a labeled bottle of wine in the medication room, and they did not have an order for it, but should have. Resident #28 did have an order for brandy. It was important that alcohol was labeled and verified the same way as medications were, the right resident and the right drink order. During an interview on 5/22/2024 at 10:42 AM, the Assistant Director of Nursing stated alcohol was locked in the medication room and required an order just like any medication. It was supposed to be labeled with the resident's name. 10NYCRR 483.45 (g)(h)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, record review, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 8 staff (Certified Nurse Aides #10, #11, #13, #20 and #21; Licensed Practical Nurses #8 and #18, and the Assistant Director of Nursing) observed; and for 1 of 2 residents (Resident #4) reviewed. Specifically, - Licensed Practical Nurse #8 did not perform hand hygiene or wear gloves when administering medication via a gastrostomy tube (feeding tube) to Resident #44 who was on enhanced barrier precautions. - Resident #25 was on contact precautions and Licensed Practical Nurse #8 did not put on the required personal protective equipment prior to entering the resident room and administering insulin; Certified Nurse Aides #10 and #11 entered Resident #25's room and did not put on personal protective equipment prior to providing care; and Certified Nurse Aide #13 entered the resident's room to remove the breakfast food items and did not wear personal protective equipment. - Resident #48 was on enhanced barrier precautions and personal protective equipment was not worn by Certified Nurse Aides #20 and #21, Licensed Practical Nurse #18, and the Assistant Director of Nursing during wound care or incontinence care. - Resident #4's urinary catheter drainage collection bag was lying directly on the floor without a barrier. Findings include: The facility policy, Infection Prevention and Control Program revised 1/2024, documented the Infection Control Program was designed to prevent, identify, report, investigate, and control the spread of infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement; and to provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations. The facility policy, Enhanced Barrier Precautions revised 3/2024, documented enhanced barrier precautions was an infection control intervention designed to reduce transmission of multidrug-resistant organisms. Enhanced barrier precautions involved gown and glove use during high-contact resident care activities for residents known to be colonized or infected with multidrug-resistant organisms as well as those at increased risk of multidrug-resistant organism acquisition (e.g., residents with wounds or indwelling medical devices). The facility policy, Tube Feedings dated 3/2017, did not address the required personal protective equipment to be used for medication administration. The undated facility policy, Contact Precautions documented a precaution sign would be placed on the outside of a resident's room door, the isolation cart (contains personal protective equipment) would be placed outside of the resident's door. Gloves would be worn by all staff who entered a resident's room and removed, and hands washed before leaving the area. Gowns would be worn by all staff providing care if their clothes could become soiled with infectious material. 1) Resident #44 had diagnoses including gastrostomy (surgically made opening into the stomach for food). The 3/2/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required maximum assistance with activities of daily living, and had a feeding tube. The comprehensive care plan initiated on 2/14/2018 documented the resident required a tube feeding as an alternative means of nutritional support for their nutrition and hydration. The 4/23/2024 physician order documented enhanced barrier precautions were to be maintained every shift. During an observation on 5/20/2024 at 10:33 AM, Licensed Practical Nurse #8 prepared medications for Resident #44. They stated the resident received all their medications through the gastrostomy tube. The nurse gathered the required medications and supplies and entered the resident's room. They did not perform hand hygiene or apply gloves. Licensed Practical Nurse #8 reached under the resident's blankets and gown for the gastrostomy tube with ungloved hands and began to prepare for medication administration by administering a water flush. Licensed Practical Nurse #8 stated, Are you marking me down for not wearing gloves? and continued to give the resident medications without wearing gloves. After attempting to give the medications through the gastrostomy tube they stated the tube seemed to be plugged and they were going to get the Unit Manager. They washed their hands in the sink prior to leaving the room. During an interview on 5/20/2024 at 11:11 AM, Licensed Practical Nurse #8 stated they should have worn gloves during the medication administration for Resident #44 to prevent the spread of germs. They thought they washed their hands prior to touching the resident's gastrostomy tube and washed their hands after completing the medication administration and that should have been good enough. During an interview on 5/21/2024 at 8:51 AM, Licensed Practical Nurse Unit Manager #1 stated staff were supposed to wear gloves any time they touched a gastrostomy tube. This was an infection control standard. The staff should have worn gloves upon entering the room. Licensed Practical Nurse #8 should have worn gloves knowing they were going to administer medications and a water flush through a gastrostomy tube. During an interview on 5/22/2024 at 11:30 AM, the Assistant Director of Nursing stated staff should wear gloves when they provided medications through a feeding tube. This was the standard of care. It was important to wear gloves to prevent the spread of pathogens from one resident to another resident. Gloves and hand hygiene were major keys to the prevention of infection in the residents. 2) Resident #25 had diagnoses including asthma, chronic respiratory failure, and diabetes. The 3/13/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required maximum assistance with activities of daily living, and had received insulin in the last 7 days. The 5/16/2024 Nurse Practitioner #44 progress note documented the resident's urinalysis (a urine test that checks for infection) and culture (a lab test that checks for bacteria in the urine) was positive for a urinary tract infection. The urine was positive for greater than 100,000 pseudomonades (a type of bacteria). The May 2024 physician orders did not document the resident was to be on contact or enhanced barrier precautions. During an observation on 5/17/2024 at 1:56 PM room had a contact precautions sign on the door. The resident's call light was alarming. Certified Nurse Aide #10 entered the room and did not apply personal protective equipment. They exited the room and stated the resident wanted their juice opened. The resident had stated to them they thought they had the flu. Certified Nurse Aide #10 did not perform hand hygiene. During an observation on 5/17/2024 at 2:13 PM, Resident #25's room had a contact precautions sign posted on the outside of the door. Certified Nurse Aides #10 and #11 started to enter the room not wearing any personal protective equipment or performing hand hygiene. The certified nurse aides paused and read the sign outside the resident's room and continued to walk into the room. There was no personal protective equipment outside of the room. At 2:21 PM, both certified nurse aides exited the room and did not perform hand hygiene. There was a small bottle of hand sanitizer observed outside the door on the railing. The current comprehensive care plan and resident care instructions did not document the resident was to be on contact precautions or enhanced barrier precautions. During an observation and interview on 5/20/2024 at 12:03 PM, there was a contact precautions sign on the resident's door. Licensed Practical Nurse #8 stated they were not sure what the sign was for and thought it was an old sign and proceeded to enter the resident's room to complete a blood sugar via fingerstick. They did not perform hand hygiene and applied gloves. Prior to exiting the room, they entered the bathroom, removed their gloves, and washed their hands. At 12:18 PM, Licensed Practical Nurse #8 prepared the resident's insulin pen, they did not use hand sanitizer or wash their hands, they put on gloves, entered the resident's contact precautions room without all the required personal protective equipment on, and administered the insulin. During an interview on 5/21/2024 at 8:58 AM, Licensed Practical Nurse Unit Manager #1 stated the contact precautions sign was for Resident #25. The resident had a recent urinary tract infection and a fall requiring staples to the forehead. For those two reasons the resident was required to be on contact precautions. Resident #25 had bacteria in their urine and all staff should have known this information. The contact precautions required staff to have full personal protective equipment on when entering the resident's room. Staff were educated on personal protective equipment on 5/17/2024 and the signs on the door instructed the staff on what personal protective equipment to wear. It was important to wear the required personal protective equipment to prevent the spread of germs and to keep the infection confined. Staff should participate in morning report to get updated information on residents and if they had questions, they should be reaching out to them. During an interview on 5/22/2024 at 9:50 AM, Certified Nurse Aide #12 and Certified Nurse Aide #13 stated they were regular staff on Unit 2. Both certified nurse aides stated they were unsure what enhanced precautions meant. Certified Nurse Aide #13 stated Resident #25 was on contact precautions last week. When they entered the room last week not wearing personal protective equipment it was okay because they were just picking up the resident's meal tray. Contact precautions was only needed when providing the resident's personal care. It was important to practice the proper infection control precautions to protect themselves and the residents from germs. During an interview on 5/22/2024 at 11:30 AM, the Assistant Director of Nursing stated if a nurse was performing a fingerstick for a blood glucose check they should be wearing gloves. If Resident #25 was on contact precautions staff should be wearing a gown to protect the resident. When staff did not wear the appropriate personal protective equipment, this was an infection control issue. 3) Resident #48 had diagnoses including urinary incontinence, diabetic foot ulcers, and unspecified skin changes. The 4/28/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for toileting, bathing, dressing, was always incontinent of bowel and bladder, had diabetic foot ulcers, and had applications of dressings to the feet. The comprehensive care plan initiated 6/12/2023 and revised 4/18/2024 documented the resident had skin breakdown to the left and right heels and open areas to the bilateral buttocks. Interventions included the resident was to be followed by the wound team on weekly rounds, signs and symptoms of infection were to be monitored, and enhanced barrier precautions were to be maintained. Resident #48's physician orders documented: - 12/29/2023 hydrophilic dressing paste that adhered to wet, eroded skin topically, once daily, in a circular motion to open areas on the left and right buttocks. - 4/15/2024 left medial heel diabetic foot ulcer, skin prep to wound base, leave open to air daily. - 4/22/2024 maintain enhanced barrier precautions every shift. - 5/17/2024 zinc cream to coccyx (lower tailbone) twice daily and as needed for prevention of skin alterations. During an observation of Resident #48's incontinence care and wound care on 5/20/2024 at 11:49 AM, Certified Nurse Aide #21 entered the resident's room with a mechanical lift machine (used to transfer residents). Certified Nurse Aide #21 put on gloves and did not perform hand hygiene and did not put on a gown. At 11:55 AM, Certified Nurse Aide #20 entered the resident's room, put on gloves, and did not perform hand hygiene, or put on a gown. They attached the mechanical lift pad to the mechanical lift and transferred the resident from their chair to their bed to perform incontinence care. At 11:59 AM, Licensed Practical Nurse #18 entered the resident's room, put on gloves, did not put on a gown, and did not perform hand hygiene. At 12:01 PM, Licensed Practical Nurse #18 removed their gloves, did not perform hand hygiene, stated they were going to get the Assistant Director of Nursing, and exited the room. At 12:02 PM Licensed Practical Nurse #18 and the Assistant Director of Nursing both entered the room, applied gloves, and did not perform hand hygiene, and did not put on a gown. At 12:06 PM Licensed Practical Nurse #18 applied zinc cream to the resident's buttocks wound wearing gloves. They removed the gloves, washed their hands, and applied new gloves and performed the wound treatment. Hand hygiene was performed by both upon exiting the room. At 12:18 PM, Certified Nurse Aides #20 and #21 transferred the resident back to their medical recliner chair after dressing the resident. Certified Nurse Aides #20 and #21 removed their gloves and exited the room without performing hand hygiene. There was no visible signage near the resident's room that documented the resident was on enhanced barrier precautions. During an interview on 5/20/2024 at 1:07 PM Licensed Practical Nurse #18 stated enhanced barrier precautions were for any resident with a wound, catheter, tube feeding, or history of a super bug (drug resistant bacteria). It was important to protect susceptible residents by wearing a gown and gloves and eye protection if there was a chance of bodily fluid splashes. They should have worn a gown when providing wound care because Resident #48 was on enhanced barrier precautions. There should have been a sign on the door that informed staff of the precautions and what personal protective equipment was needed but it must have fallen off. During an interview on 5/22/2024 at 10:42 AM the Assistant Director of Nursing stated residents who had urinary catheters or wounds were on enhanced barrier precautions. Personal protective equipment was worn with treatment or care such as incontinence care, bathing, or emptying a urinary drainage bag. Resident #48 was on enhanced barrier precautions and they and the other staff members who performed wound care and incontinence care during the observation on 5/20/2024 should have all had at least gowns on. This was important to prevent the spread of infection from one person to another. During an interview on 5/22/2024 at 10:55 AM, the Infection Preventionist stated contact precautions were for residents with infections like clostridium-difficile (an intestinal bacteria), stomach bugs, or urinary tract infections with multiple drug resistant organisms. Staff were required to wear gowns, gloves, masks, and shields when performing care. If a resident had a laceration, abrasion, or a gastrostomy tube feeding they should be on enhanced barrier precautions. Gloves should be worn when performing gastrostomy tube feedings, flushes, or administration of medications for infection prevention control purposes. It was the standard of care to wear gloves for gastrostomy tube feedings, medication administration and flushes. Gloves kept the resident safe. All staff should wear gloves and gowns for enhanced barrier precautions. Whenever a resident was put on precautions, they went to the unit to verify that it was needed. They put an orange dot on the resident's name outside the door and put signage on the back of the door for enhanced precautions. The signs on the front of the door were for contact precautions. During a follow-up interview on 5/22/2024 at 11:30 AM, they stated enhanced barrier precautions were a step above standard precautions to stop the transmission of infections between residents and staff. Gown and gloves were required, and masks were optional and should be used if there was a risk of bodily fluid spray. Residents on enhanced barrier precautions were those that had multi-drug resistant organisms, catheters, gastrostomy tube feedings, open wounds, surgical wounds, or central line devices. Resident #48 was on enhanced barrier precautions for their wounds. Gowns and gloves were required for all the resident's wound care, incontinence care, or any other hands-on care. It was not appropriate that gowns were not worn during wound and incontinence care of Resident #48 because staff could spread infections or give the resident an infection. 10 NYCRR 415.19(a)(b)

CONCERN (E)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 3 nursing floors (first and second floors). Specifically, there was evidence of drain flies and fruit flies on the first and second floors. Findings include: The Pest Sighting Service Report Log, located in the mail room, documented that no pests were observed by staff from 2/28/2024 to 4/24/2024. The Pest Control Vendor Invoice documented that no pests were observed from 2/28/2024 to 4/24/2024. The Pest Siting Service Report and the Pest Control Vendor Invoice forms did not document the facility areas checked by the vendor. The following observations were made: - on 5/16/2024 at 11:40 AM in the second floor Ridge side spa room, there were 4 live drain flies and multiple dead drain flies. - on 5/17/2024 at 12:15 PM in the second floor kitchenette, there was 1 live fruit fly. - on 5/17/2024 at 12:30 PM in the first floor kitchenette, there were 2 live fruit flies. - on 5/20/2024 at 9:45 AM in the first floor kitchenette, there were 2 live fruit flies. - on 5/20/2024 at 9:59 AM in the second floor kitchenette, there were 2 live fruit flies. During an interview on 5/21/2024 at 11:55 AM, the Director of Environmental Services stated if staff saw pests, they should report it to the housekeeping team lead or a supervisor. They stated the pest control vendor had been doing monthly inspections of the facility for the last three months and no pests had been identified. There were nine drains that were treated to prevent pests and they were not sure if the second floor Ridge spa room drain was included on this list. They stated work orders were entered when staff emailed or called the maintenance department, and all staff should be documenting pests in the mail room pest sighting log. The Director of Environmental Services stated it was important that all areas of facility were checked for pests. During an interview on 5/22/2024 at 9:38 AM, the Food Service Director stated they were not aware of any fruit flies in the first and second floor kitchenettes. They stated the main kitchen utilized a separate pest control vendor from the rest of the facility, and they came monthly. The Food Service Director stated the other vendor checked the rest of the facility for pests. The Food Service Director stated the drains in the facility kitchenettes had a monthly drain treatment done by a vendor, and this treatment could also be completed as needed. 10NYCRR 415.29(j)(5)

Sept 2023 4 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · 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 the abbreviated survey (NY00322111), the facility failed to ensure each resident had the right to be free from neglect for 1 of 4 residents reviewed (Resident #4). Specifically, on [DATE], the resident was not provided with services that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Surveillance video of the nursing unit from [DATE] at approximately 7:38 PM, revealed a resident falling backwards off a partition (separating the dining room from the hallway) that was approximately 27 inches in height and hitting their upper back on the floor in the hallway. The resident remained on the floor for approximately two and a half hours while 5 certified nurse aides (CNAs #1, 16, 17, 18, and 26), 1 licensed practical nurse (LPN #5), 1 resident helper (resident helper #27), and the housekeeper (housekeeper #47) walked by the resident without attending to the resident and without notifying a registered nurse (RN Supervisor #4) to complete an assessment. After approximately 2 hours, the resident unsuccessfully attempted to get up and tipped over twice. Shortly thereafter, the resident got themselves into a kneeling position and attempted to use the handrail to stand and fell over. This occurred 3 more times until 10:20 PM when CNA #17 and resident helper #27 transferred the resident into a wheelchair (without RNS #4 present for an assessment). RNS #4 arrived on the unit several minutes after the resident was transferred to the wheelchair and shortly thereafter pronounced the resident deceased . Furthermore, the facility failed to report the incident as required. This resulted in Immediate Jeopardy to Resident #4. Findings include: The Falls policy, revised [DATE], documented a fall was defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface. A fall may be witnessed, reported by the resident or an observer, or identified when a resident was found on the floor/ground. In the event a resident fell or was found on the ground, a head-to-toe evaluation must be performed. Upon arrival of the nurse, a quick head-to-toe scan was to be performed without unnecessary movement, palpating, and examining all areas for breaks in the skin and/or other abnormal findings and staff were to obtain vital signs, neurological checks for unwitnessed falls or falls with head injury, and obtain blood sugar if the resident was diabetic. If there was no obvious injury, the resident could be moved to a comfortable position. The Criteria for Assessing Changes in Resident's Condition policy, revised 6/2003, documented it was the policy of the facility to evaluate sudden changes in a resident's condition and assessing. Sudden changes in condition were defined as a change in level of consciousnesses, delirium, lethargy, unresponsiveness, vomiting, elevated temperature, or a change in oxygen saturation level, blood glucose, or blood pressure. The policy listed the Medical Director as being available for communication 24 hours per day 7 days a week. The Abuse policy (undated) documented residents will be protected from neglect while at the facility. An intervention used by the facility to prevent abuse/neglect included staff will be supervised to identify inappropriate behaviors while caring for or in attendance with residents. The facility's policy addressed investigating allegations of mistreatment, neglect, and abuse promptly and thoroughly. If an investigation showed mistreatment, employees would be disciplined and reported to appropriate licensing boards. The facility policy also included reporting abuse, neglect, and mistreatment according to Federal and State laws. The Administrator or designee was responsible for the initial reporting to the New York State Department of Health (NYS DOH) The resident helper job description documented the resident helper was responsible for non-nursing tasks and listed duties the person may perform. The list of duties did not include transferring residents. Resident #4 had diagnoses including a past traumatic brain injury (TBI) following an accident. The [DATE] Minimum Data Set (MDS, an assessment tool) assessment documented the resident had severe cognitive impairment, exhibited physical behaviors on 4-6 days of the assessment period, and verbal and other behaviors on 1-3 days of the assessment period. The resident's behaviors impacted the resident, significantly interfered with care, interfered with activities and social interactions, put others at risk for significant injury, and significantly disrupted care or the living environment. The resident was independent with transfers and ambulation in their room and needed supervision with ambulation in the corridor. The resident had no falls in the month prior to admission and had a fall/falls in the 2-6 months prior to admission with no serious injuries. The [DATE] former registered nurse (RN) Manager #19's progress note documented the resident was admitted from another skilled nursing facility. The resident had a past head injury from an accident and was independent with ambulation, transfers, eating, and toileting. The comprehensive care plan (CCP), initiated on [DATE], documented the resident was at risk for falls and staff were to investigate the cause of falls immediately, evaluate patterns of falls, and request rehabilitation referrals when needed. The [DATE] certified nurse aide (CNA) Assignment Sheet (care instructions) documented the resident was independent with transfers and bed mobility and required supervision with ambulation. There was no documentation in the CCP or CNA Assignment Sheet the resident had a behavior or history of placing themselves on the floor. The [DATE] Incident Report completed by the Director of Nursing (DON) documented on [DATE] at 7:30 PM, an unidentified certified nurse aide (CNA) reported to an unidentified licensed practical nurse (LPN) the resident was on the floor near the dining room in the hallway. The resident had a history of putting themselves on the floor and getting up on their own and was noted to be without injury related to the fall. Staff education was to be done to get residents off the floor in common areas and to read the CCP on all residents. The DON documented the CCP was followed, the investigation did not support abuse, neglect, or mistreatment, and there was not a failure to provide timely, safe, consistent, and adequate care and treatment to the resident. Included with the [DATE] Incident Report were statements obtained by the facility including: - statements from CNAs #1, 16, 17, 18 and 26 who documented on [DATE], the resident was on the floor during the evening shift. - CNA #1 noted on [DATE] at around 10:00 PM, they were leaving the unit for break and saw the resident laid out on the floor in the hallway. They called the resident's name 3 times, and the resident did not respond. They told licensed practical nurse (LPN) #5 the resident was on the floor and LPN #5 said it was fine. CNA #1 left for break and when they returned, the resident was sitting up in a chair looking ghostly pale, slumped over. Registered nurse Supervisor (RNS) #4 was present. - LPN #5 documented on [DATE] at 8:30 PM, they noticed the resident was on the floor and the resident placed themselves on the floor on many occasions. They interacted with the resident at 8:50 PM. At 10:10 PM, they noted something brown around the resident's mouth and called a CNA (unidentified) to get the resident off the floor. At 10:20 PM, LPN #5 called RNS #4 and when RNS #4 responded, the resident was up in the wheelchair. They attempted to obtain vital signs and RNS #4 pronounced the resident deceased . The facility's surveillance video from the nursing unit was reviewed from [DATE] from 7:29 PM through 10:58 PM, and the following was observed: - at 7:38 PM, the resident, whose back was seen just in frame view, was sitting on a partition (separating the dining room from the hallway, approximately 27 inches in height) and fell backwards. The resident's legs went up in the air and the resident's back struck the floor. After falling, the resident moved themselves, so their head was next to the wall, propped on a door jamb, with their legs outstretched and positioned parallel with the hallway. - At 7:41 PM, CNA #26 entered a room across the hall from where the resident was and did not approach the resident and LPN #5 walked by the resident without stopping. - At 7:42 PM, the resident turned themselves, so their head was against the wall. LPN #5 and CNA #26 walked by the resident and neither stopped. - Between 7:47 PM and 7:55 PM, LPN #5 checked the resident's blood sugar as the resident was lying on the floor, went to the nursing office, and returned a few moments later to check the resident's blood sugar a second time; housekeeper #47 and CNAs #16 and 18 walked by twice; housekeeper #47 started mopping the dining room floor (the resident was on the floor right outside the entryway into the dining room), and CNA #26 went to the linen cart which was less than 2 feet from where there resident was lying in the hallway. - At 7:56 PM, the resident straightened their legs, so they were outstretched across the hallway and propped them against a door jamb. The resident was blocking most of the hallway with their legs. - Between 7:57 PM and 8:45 PM, CNA #26 walked by the resident 5 times (once walking around the resident's legs); CNA #16 walked by twice; Resident Helper #27 and CNA #26 wheeled an unidentified resident in a chair past Resident #4 while maneuvering the chair to get around Resident #4's legs; CNA #18 assisted an unidentified resident to walk by and then walked by alone, and housekeeper #47 walked by twice. None of the staff stopped. - At 8:51 PM, the resident hit their hand with a clenched fist against the floor 4-5 times. - Between 8:52 PM and 9:01 PM, CNA #17 walked by, appeared to look at the resident, and did not stop. At 8:56 PM, CNA #17 and LPN #5 walked by. The resident was sitting with their knees bent, leaned forward at the waist. - Between 9:02 PM and 9:03 PM, the resident attempted to stand twice by placing one foot flat on the floor and pressing up with their hand. The second time, the resident got themselves into a kneeling position and on their hands and knees. The resident sat back down, bent at the waist with their head down. - At 9:04 PM, LPN #5 walked by and did not stop. - At 9:05 PM, the resident pushed their right hand into floor, tried to push themselves up, and returned to sitting, bent at the waist. - At 9:06 PM, the resident placed their left foot and right hand on the ground and attempted to lift their buttocks off the floor. The resident continued this until 9:13 PM and then pounded their right hand onto the ground a few times. - At 9:28 PM, CNA #16 looked down the hallway where the resident was and entered the nurse's office. - At 9:37 PM, the resident used their right hand to push themselves up and was sitting with their right hand on the floor. The resident tipped over and their weight went from their hand to their elbow. The resident did this a second time and at this time, an unidentified person's body and hands was seen in the dining room with their hands gesturing at the resident. The resident gestured at the unidentified person in the dining room and kicked their leg in the direction of the unidentified person. The unidentified person did not step into camera view. - At 9:38 PM, the resident tried to press themselves up and at 9:40 PM the unidentified person was seen in the dining room with their hands gesturing towards the resident. The resident tipped over and fell onto their left side and laid on the floor in a curled up position. - At 9:44 PM, CNA #1 walked out of the nurse's office, towards the unit exit, and then turned around and looked in the direction of the resident. CNA #1 walked back into the nurse's office and then exited the office and the unit 1 minute later. - At 9:49 PM, the resident pushed themselves to a sitting position and was slumped over with their head down. The resident fell over to the right side and was lying down in a curled up position. CNA #17 entered the room (kitchen) next to where the resident was and did not approach the resident. The resident pushed themselves to a sitting position and to a high kneeling position. They tried to reach out for the wall/handrail, fumbled for it with their hands, used their left hand to push on their thigh, and then fell over backwards. They were now on the floor with their back and head against the wall. - At 9:50 PM, the resident pushed themselves to a sitting position with knees bent and their head against the wall, slumped down. - At 9:54 PM, the resident rolled from side to side and hit their right hand on the floor. - Between 9:55 PM and 9:56 PM, the resident pushed themselves to a sitting position and then fell backwards into a lying position twice. - At 10:01 PM, CNA #16 looked towards the resident from a distance and did not approach the resident. - At 10:06 PM, the resident pushed themselves to a sitting position, slumped forward, and then tipped over to a lying position. - At 10:07 PM, the resident pushed themselves to a sitting position, got onto their hands and knees, reached out for the handrail, and fell to the right side. The resident was lying in a curled up position. - At 10:09 PM, the resident pushed themselves to a sitting position and tipped over to a lying position and then pushed themselves to sitting, dropped to their elbows, and then tipped over to a lying position. - At 10:14 PM, the resident pushed themselves to a sitting position, tipped over again lying on their side and then repeated this again. - At 10 :17 PM, LPN #5 exited the nurse's office and entered the medication room which was in the same hallway where the resident was on the floor. - At 10:18 PM, LPN #5 walked to the resident and talked to them. At 10:19 PM, the resident pushed themselves to siting and LPN #5 walked away. - At 10:20 PM, CNA #17 exited the doorway next to the where the resident was (kitchen), looked at the resident, and the resident rolled to their left side. CNA #17 walked to the nurse's office and resident helper #17 looked in the resident's direction from a distance and entered the nurse's office. - At 10:23 PM, CNA #17 and resident helper #27 physically assisted the resident into a wheelchair and wheeled the resident down the hallway to outside of the nurse's office. LPN #5 was not present when the resident was transferred and exited the nurse's office when CNA #17 and resident helper #27 arrived. LPN #5 spoke to staff and walked away. CNA #17 and resident helper #27 walked away. Resident helper #27 entered the nurse's office and CNA #17 returned to camera view a few seconds later and applied a clothing protector to the resident. The resident was sitting in a wheelchair, slumped to the left side with their head down, and their feet under the chair. The resident had deep, rapid respirations. CNA #17 fixed the resident's feet and resident helper #27 returned with a Styrofoam cup with a straw in it that they placed on the handrail. CNA #17 rubbed the resident's head and LPN #5 exited the nurse's office at the same time RNS #4 arrived to the unit (3 minutes after the resident was assisted off the floor). LPN #5 and RNS #4 attempted to obtain a blood pressure, LPN #5 obtained a temperature (ear); RNS #4 obtained a blood sugar, and RNS #4 listened to the resident's heart and lungs with a stethoscope. At 10:35 PM, CNA #17 removed the blood pressure cuff from the resident's arm. During an interview on [DATE] at 11:42 AM, CNA #16 stated on [DATE], the resident was lying on the floor near the dining room after dinner, they did not know what time but stated dinner was around 5:30 PM, and CNA #1 let LPN #5 know. CNA #16 stated themselves and CNA #1 asked the resident to get up, but the resident looked at them and did not speak. CNA #16 stated they did not know if LPN #5 directed CNA #1 to do anything when they reported the resident was on the floor. CNA #16 left the facility at 8:00 PM or 9:00 PM and the resident was lying on the floor when they left. During an interview on [DATE] at 12:44 PM, CNA #18 stated the resident usually sat on the floor in the evening and when the resident did that, they let the nurse know and asked the resident to get up. CNA #18 stated it was up to the LPN to let an RNS know if the resident seemed hurt. CNA #18 left the facility at 9:00 PM on [DATE] and the resident was sitting on the floor in the hallway when they left. They stated they let LPN #5 know the resident was on the floor that shift. During an interview on [DATE] at 3:25 PM, CNA #17 stated the resident was typically on the floor in the hallway and when CNA #17 saw this they reported it to a nurse. On [DATE], they first saw the resident on the floor around 8:30 PM or 8:45 PM and did not think it was odd but at 9:00 PM, the resident remained on the floor and did not respond verbally to CNA #17. They thought this was unusual, so they let LPN #5 know the resident was not speaking and they saw something brown come out of the resident's mouth. CNA #17 stated LPN #5 had them get the resident up and put them in a wheelchair and they could not recall who assisted them with this. During an interview on [DATE] at 12:08 PM, CNA #1 stated on [DATE] after 9:00 PM, when they were leaving the unit for a break, they saw the resident on the floor. They went to the resident and said their name and they moved a little, but they did not talk so they said the resident's name 2 more times. The resident did not speak, move, or get up. CNA #1 reported this to LPN #5 who said it was okay and CNA #1 went to break. When they got back from break, the resident was in the wheelchair, was ghostly pale, and RNS #4 was there. During an interview on [DATE] at 1:42 PM, RNS #4 stated on [DATE] during the evening shift, they did not see the resident until LPN #5 called them and reported the resident was lying on the floor, eating feces. When RNS #4 arrived to the unit, the resident was in a wheelchair, their skin was mottled (occurs when near the end of life, red and purple spots appear on skin and spread up the arms and legs), they had no blood pressure, so they pronounced the resident deceased . RNS #4 was told by LPN #5 when they got the resident up in the chair, coffee ground emesis (indicative of a stomach bleed) came out of their mouth. RNS #5 stated eating feces was not normal behavior for the resident and with a change in condition, staff should not get a resident off the floor without an RN assessment. During an interview on [DATE] at 3:49 PM, LPN #5 stated on [DATE], they did not recall the first time they saw or interacted with the resident, but it was likely at dinner time. The resident was first noted to be on the floor after dinner probably. LPN #5 stated the resident picked at things that were not there when they sat on the floor. That evening, the resident did not respond to them when they were on the floor but that was usual as the resident responded to people they liked, and the resident did not like LPN #5. LPN #5 stated they did not see the resident in distress when they were on the floor and extended their hand and offered assistance multiple times. They stated no staff told them the resident was on the floor. They noticed it themselves and asked the CNAs why the resident was on the floor. They did not call an RNS as they did not think the resident being on the floor was a fall. They stated they did call RNS #4 when the resident had brown around their mouth and fingers, and they thought they were eating feces. During an interview on [DATE] at 5:00 PM, the DON stated: - they completed all aspects of the incident investigation process. They reviewed all incident reports, updated CCPs, and ensured investigations were complete. - The DON, former Administrator #49, the Chief Executive Officer (CEO) ruled out abuse/neglect and determined what was reportable to the NYS DOH. - The DON completed the investigation into the resident being on the floor on [DATE] when they found out about it on [DATE] in morning report. RNS #4 should have started an incident report on [DATE] and did not. During the investigation, the DON found that at least 3 staff members told LPN #5 the resident was on the floor and LPN #5 never checked on the resident. LPN #5 was re-educated as they did not have the resident assessed when they were on the floor. - The DON did not personally review the entire video from [DATE] when they completed the investigation. They could not access video footage on their own and the CEO and former Administrator #49 watched it and typically, former Administrator #49 reported to the DON what they saw or would have the DON watch certain portions of video. The DON watched about 12 minutes of the video and did not see the resident fall, nor were they told the resident fell. - If a resident fell, there should be an assessment, neurological checks, provider/family notification, 3 days of notes monitoring the resident, and the staff should have gotten the resident off the floor. - LPN #5 did not call RNS #4 as they did not think the resident fell. - When LPN #5 thought the resident had coffee ground emesis, that would be a change in condition, and they should not have moved the resident without an assessment. - Resident helper #27 should not have provided any hands on care, should not have assisted the resident off the floor, and the DON was not aware they had. Resident helper #27 was not on the assignment sheet and when the DON did the investigation, they did not know resident helper #27 was working. - The DON did not investigate the resident's death because they did not think the death was related to a fall and they could not determine if the resident fell. They stated they saw the resident on the floor, rolling and sitting. They mostly saw the portions of the video with LPN #5 as they were responsible for the re-education of LPN #5, and they were not told by former Administrator #49 that the resident fell. During an interview on [DATE] at 11:10 AM, NP #3 stated they were notified on [DATE] that the resident expired. Initially they were told the resident had an unresponsive episode but as time went by, they heard other accounts of what happened including lack of response by the LPN to reports from a CNA and also the possibility that a fall occurred. NP #3 watched the video from the nursing unit on [DATE] with former Administrator #49 and the CEO. They saw the resident fall and did not know if they struck their head. The video was long, so they fast forwarded through a lot of it. After watching the video, the NP told former Administrator #49 and the CEO their concern was the time lapse of the resident being on the floor with no one assisting them. During an interview on [DATE] at 9:00 AM, the CEO stated they did not have a hands-on role in investigations. In this case, there was a discussion on [DATE] and since they had access to the video, they pulled the video and Former Administrator #49, and the DON watched it as they were responsible for the investigation. Former Administrator #49 watched the video, and the DON was in and out of the office when it was playing. Former Administrator #49 and the DON told the CEO they were interviewing everyone involved and the CEO would not have a role in reviewing staff statements. The CEO stated they were not medical, but the resident fell and was on the floor for quite some time. Former Administrator #49 did not see the video as alarming, but the concern was that people were walking by the resident when they were on the floor. The staff stated being on the floor was the resident's typical behavior. Former Administrator #49 was called for an interview on [DATE] and did not reply to the message. Attempts were made on [DATE] and [DATE] to reach housekeeper #47 and resident helper #27 for interviews and no responses were received. 10NYCRR 415.4(b) ------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility CEO and DON were notified on [DATE] at 3:59 PM. Immediate Jeopardy was removed on [DATE] at 11:30 AM prior to survey exit based on the following corrective actions taken: - 100% of staff on duty were educated according to the approved training plan. - 17 staff from various departments were interviewed and confirmed participation and understanding of the education (dietary, housekeeping, activities, nursing). - The facility developed a plan to educate any staff not working prior to the start of their shift with education to be done by the Assistant Director of Nursing (ADON) Educator, ADON Supervisor, DON, or RN Manager #30.

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

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, record review, and interview during the abbreviated survey (NY00322111), the facility did not ensure all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated; did not ensure residents were protected while the investigation was in process and did not ensure incidents were reported to the New York State Department of Health (NYS DOH) when required for 1 of 4 residents reviewed (Resident #4). Specifically, Resident #4 was found on the floor by staff on [DATE] and remained on the floor without a registered nurse (RN) assessment for approximately two and a half hours and when the resident was assisted off the floor, they expired shortly thereafter. The facility's investigation was not thorough and complete as it did not: - Identify neglect occurred when 5 certified nurse aides (CNAs #1, 16, 17, 18, and 26), 1 licensed practical nurse (LPN #5), 1 resident helper (resident helper #27), and 1 housekeeper (housekeeper #47) walked by the resident for approximately two and a half hours without attending to the resident and without notifying a registered nurse (RN) for an assessment and when the resident was assisted off the floor without an RN assessment by resident helper #27. - Identify or address discrepancies in CNA #1's statement when compared with video surveillance. - Attempt to identify a person seen (just off camera view) interacting with the resident when the resident was attempting to stand unsuccessfully, and they did not provide assistance to the resident. - Address the resident's fall and subsequent death (approximately two and a half hours later) and did not rule out abuse/neglect related to the resident's death. Additionally, the facility did not protect residents from further potential neglect while the investigation was pending and did not report to the NYS DOH when abuse/neglect was not ruled out. Findings include: The Falls policy, revised [DATE], documented in the event a resident fell or was found on the ground, a head-to-toe evaluation must be performed. The Abuse policy (undated) documented residents will be protected from neglect while at the facility. An intervention used by the facility to prevent abuse/neglect included staff will be supervised to identify inappropriate behaviors while caring for or in attendance with residents. The facility's policy addressed investigating allegations of mistreatment, neglect, and abuse promptly and thoroughly. If an investigation showed mistreatment, employees would be disciplined and reported to appropriate licensing boards. The facility policy also included reporting abuse neglect and mistreatment according to Federal and State laws. The Administrator or designee was responsible for the initial reporting to the New York State Department of Health (NYS DOH) The Resident Helper job description documented the Resident Helper was responsible for non-nursing tasks and listed duties the person may perform. The list of duties did not include transferring residents. Refer to F 600 Resident #4 had diagnoses including a past traumatic brain injury (TBI) following an accident. The [DATE] Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, exhibited physical behaviors on 4-6 days of the assessment period, and verbal and other behaviors on 1-3 days of the assessment period, was independent with transfers and ambulation in their room and needed supervision for ambulation in the corridor. The resident had no falls in the month prior to admission and had falls in the 2-6 months prior to admission with no serious injury. The [DATE] former registered nurse (RN) Manager #19's progress note documented the resident was admitted from another skilled nursing facility. The resident had a past head injury from an accident and was independent with ambulation, transfers, eating, and toileting. The comprehensive care plan (CCP), initiated on [DATE], documented the resident was at risk for falls and staff were to investigate the cause of falls immediately, evaluate patterns of falls, and request rehabilitation referrals when needed. The [DATE] certified nurse aide (CNA) Assignment Sheet (care instructions) documented the resident was independent with transfers and bed mobility and required supervision with ambulation. The [DATE] Incident Report completed by the Director of Nursing (DON) documented on [DATE] at 7:30 PM, an unidentified certified nurse aide (CNA) reported to an unidentified licensed practical nurse (LPN) the resident was on the floor near the dining room in the hallway. The resident had a history of putting themselves on the floor and getting up on their own and was noted to be without injury related to the fall. Staff education was to be done to get residents off the floor in common areas and to read the comprehensive care plan (CCP) on all residents. The DON documented the CCP was followed, the investigation did not support abuse, neglect, or mistreatment, and there was not a failure to provide timely, safe, consistent, and adequate care and treatment to the resident. Included with the [DATE] Incident Report were statements obtained by the facility including: - statements from CNAs #1, 16, 17, 18 and 26 who documented on [DATE], the resident was on the floor during the evening shift. - CNA #1's statement written on [DATE] documented on [DATE] at around 9:40 PM to 9:49 PM, the resident was standing at the nurse's station entrance banging on the door shaking while their face, arms, and hands were flush red. CNA #1 asked the resident if they were okay and they did not respond so they asked again and licensed practical nurse (LPN) #5 stated the resident was fine and told the resident to go sit down. CNA #1 went back to work and when they went to leave the unit for break at 10:00 PM, they saw the resident laid out on the floor. They called the resident's name 3 times, the resident did not respond, and they told LPN #5 who said it was okay as the resident was care planned to be on the floor. CNA #1 went on break and when they returned, the resident was sitting up in a chair looking ghostly pale, slumped over. Registered nurse Supervisor (RNS) #4 was present. - LPN #5 documented on [DATE] at 8:30 PM, they noticed the resident was on the floor and the resident placed themselves on the floor on many occasions. They interacted with the resident at 8:50 PM. At 10:10 PM, they noted something brown around the resident's mouth and called a CNA (unidentified) to get the resident off the floor. At 10:20 PM, LPN #5 called RNS #4 and when RNS #4 responded, the resident was up in the wheelchair. They attempted to obtain vital signs and RNS #4 pronounced the resident deceased . The facility's surveillance video from the nursing unit was reviewed from [DATE] from 7:29 PM through 10:58 PM, and the following was observed: - at 7:38 PM, the resident, whose back was seen just in frame view, was sitting on a partition (separating the dining room from the hallway, approximately 27 inches in height) and fell backwards. The resident's legs went up in the air and the resident's back struck the floor in the hallway. After falling, the resident moved themselves, so their head was next to the wall, propped on a door jam, with their legs outstretched and positioned parallel with the hallway. - Following the fall, the resident remained on the floor, either laying down or sitting, and did not get up again until assisted into a wheelchair by CNA #17 and Resident Helper #27 at 10:23 PM. - From the time the resident fell until they were assisted off the floor, CNAs #1, 16, 17, 18, and 26, LPN #5, and Resident Helper #27 were observed on the unit and walked by the resident without assisting the resident off the floor. - At 9:37 PM, the resident used their right hand to push themselves up and was sitting with their right hand on the floor. The resident tipped over and their weight went from their hand to their elbow. The resident did this a second time and at this time, an unidentified person's body and hands could be seen in the dining room with their hands gesturing at the resident. The resident gestured at the unidentified person in the dining room and kicked their leg in the direction of the unidentified person standing in the dining room. The unidentified person did not step into camera view. - At 9:38 PM, the resident tried to press themselves up and at 9:40 PM, the unidentified person could be seen in the dining room with their hands gesturing towards the resident. The resident tipped over and fell onto their left side and laid on the floor in a curled up position. - At 10:23 PM, CNA #17 and Resident Helper #27 physically assisted the resident into a wheelchair and wheeled the resident down the hallway to outside of the nurse's office. LPN #5 was not present when the resident was transferred and exited the nurse's office when CNA #17 and Resident Helper #27 arrived. RNS #4 arrived to the unit and pronounced the resident deceased . During an interview on [DATE] at 2:35 PM, CNA #17 stated on [DATE], they first saw the resident on the floor around 8:30 PM or 8:45 PM and did not think it was odd but at 9:00 PM, the resident remained on the floor and did not respond verbally. They thought this was unusual, so they let LPN #5 know the resident was not speaking and they saw something brown come out of the resident's mouth. CNA #17 stated LPN #5 had them get the resident up and put them in a wheelchair and they could not recall who assisted them in doing this. During an interview on [DATE] at 12:08 PM, CNA #1 stated on [DATE] at 9:00 PM, the resident was pounding on the desk in the nurse's office while CNA #1 was looking at some paperwork. CNA #1 asked the resident if they were okay, and LPN #5 stated the resident was fine and told the resident to sit down which the resident did. CNA #1 stated the resident left the office and went to sit. After CNA #1 was done with their assignment, they noticed the resident on the floor when they were leaving for break. The resident moved but did not reply verbally so CNA #1 said their name 2 more times. When they did not reply again, they told LPN #5. LPN #5 said the resident was okay and was care planned to be on the floor. CNA #1 left for break and when they returned, the resident was in a wheelchair looking ghostly pale and RNS #4 was there. CNA #1 went back to the location of their assignments and did not know what happened after that. During a second interview on [DATE] at 9:58 AM, CNA #1 stated they wrote the statement included with the [DATE] Incident Report on [DATE] and the details were fresh in their mind when they wrote it. CNA #1 stated there was no way they had the wrong night when they wrote the statement and they were positive the resident was up walking around 9:00 PM, banging on the door to the nurse's office. During an interview on [DATE] at 5:00 PM, the DON stated: - they completed all aspects of the incident investigation process. They reviewed all incident reports, updated CCPs, and ensured investigations were complete. - The DON, former Administrator #49, the Chief Executive Officer (CEO) ruled out abuse/neglect and determined what was reportable to the NYS DOH. - The DON completed the investigation into the resident being on the floor on [DATE] when they found out about it on [DATE] in morning report. RNS #4 should have started an incident report on [DATE] and did not. During the investigation, the DON found that at least 3 staff members told LPN #5 the resident was on the floor and LPN #5 never checked on the resident. LPN #5 was re-educated as they did not have the resident assessed when they were on the floor. - The DON did not review the entire video from [DATE] when they completed the investigation. They could not access video footage on their own and the CEO and former Administrator #49 watched it and typically, former Administrator #49 reported to the DON what they saw or would have the DON watch certain portions of video. The DON watched about 12 minutes of the video and did not see the resident fall, nor were they told the resident fell. - Resident Helper #27 should not provide any hands on care, should not have assisted the resident off the floor, and the DON was not aware of this. Resident Helper #27 was not on the assignment sheet and when the DON did the investigation, they did not know resident helper #27 was working. - They did not investigate the resident's death because they did not think the death was related to a fall and they could not determine if the resident fell. They stated they saw the resident on the floor, rolling and sitting. They mostly saw the portions of the video with LPN #5 as they were responsible for the re-education of LPN #5, and they were not told by former Administrator #49 that the resident fell. Former Administrator #49 was called for an interview on [DATE] and did not reply to the message. 10NYCRR 415.4(b)

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 record review and interview during the abbreviated survey (NY00322111) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #4) reviewed. Specifically, Resident #4 had medical orders including: - a one-time dose of 200 milligrams (mg) of Seroquel (antipsychotic medication) and was administered the one-time dose in addition to the routine dose of 150 mg Seroquel on 6 consecutive days. - Finger sticks (blood glucose monitoring) before meals and at bedtime and call the medical provider if the result was less than 70 milligrams/deciliter (mg/dl). The resident had a fingerstick of 64 mg/dl and there was no documented evidence the medical provider was notified. - Diazepam (Ativan, sedative used to treat seizures) as needed for seizures, call 911 if the seizure lasted more than 5 minutes. The resident had a seizure lasting 10 minutes, was not administered diazepam, and 911 was not called as ordered. Findings include: The facility policy Blood Glucose Monitoring revised 2/11/2023 documented the medication licensed practical nurse (LPN) would verify the provider order, obtain the glucose reading, record the blood glucose result in the eMAR (electronic medication administration record), and notify the registered nurse (RN)/physician of any critical results. The LPN would document the date and time of testing and the results in the resident's chart, document the date and time and name of practitioner notified of the test results, and record any orders given by practitioner and the resident's response to interventions. The facility policy Medication Administration revised 2/11/2023 documented when a specific time of administration was ordered for a one dose only medication, it was entered on the eMAR (electronic medication administration record) in the same manner as a regularly scheduled medication and discontinued after the dose was given. The facility licensed staff would input an electronic medical order that was transmitted to the pharmacy and included order date, resident name and date of birth , medication name and strength and when indicated, indication for use, and directions for use. Resident #4 was admitted to the facility with diagnoses including traumatic brain injury (TBI), panhypopituitarism (production and secretion of certain hormones by the pituitary gland are reduced), and seizures. The 4/28/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was independent or required supervision for most activities of daily living (ADLs), had behavioral symptoms directed toward others, and received antipsychotic medications daily. Antipsychotic Medication (Seroquel) The comprehensive care plan (CCP), effective 4/21/2023, documented the resident used psychotropic medications. Interventions included administer medications as ordered, evaluate as needed for possible decrease in dosage, provide 1:1 interactions, and educate family/resident regarding possible side effects. Physician #2 orders dated 4/21/2023 documented Seroquel 50 mg once daily at 9:00 AM, and 100 mg once daily at 9:00 PM for obsessive-compulsive disorder. A 5/4/2023 progress note by social worker #15 documented the resident had a physical altercation with another resident. The resident was throwing things on the unit and required constant redirection. A 5/5/2023 at 3:23 PM licensed practical nurse (LPN) #8's progress note documented the resident was receiving intense surveillance. The resident continued to throw silverware at tablemates and staff during meals. A 5/5/2023 physician #2 progress note documented the resident was potentially a danger to themselves and others. The plan was to increase Seroquel to 100 milligrams (mg) twice daily, see how the resident did with that, and adjust accordingly. A 5/5/2023 physician #2 order documented Seroquel was increased to 100 mg at 9:00 AM. Nursing progress notes from 5/6/2023-5/16/2023 documented the resident had frequent behavioral symptoms including throwing items at staff and residents, pacing, striking other residents, smearing stool on other residents, throwing a laptop computer, stomping on another resident's feet, and pushing residents in their wheelchairs. The resident was difficult to redirect and was placed on intense surveillance. A 5/16/2023 nurse practitioner (NP) #3 order documented Seroquel 150 mg twice daily at 9:00 AM and 9:00 PM. Nursing progress notes from 5/17/2023-6/1/2023 documented the resident remained on intense surveillance, attempted to wander into other resident rooms, touch other residents, throw objects, was verbally abusive, and was resistant to redirection. A 6/1/2023 at 10:21 AM LPN Manager #9 progress note documented the resident pushed another resident from their wheelchair onto the floor. A 6/1/2023 at 8:00 PM nurse practitioner (NP) #3 progress note documented they had been continuously monitoring the resident for erratic and impulsive behaviors since admission. The plan was to continue to increase Seroquel until therapeutic benefit was achieved/maximum dose was reached per recommendation of consulting psychiatrist. The dose was increased to 200 mg twice daily. Continue to monitor and titrate Seroquel as behaviors warranted and continue to collaborate with psychiatrist. A 6/1/2023 NP #3 order documented Seroquel 200 mg twice daily at 9:00 AM and 9:00 PM and the order was renewed by physician #2 on 6/16/2023. Nursing progress notes from 6/2/2023-6/25/2023 documented the resident continued to require intense supervision, threw objects, entered rooms, and required frequent redirection. The frequency of behavioral symptoms had decreased. A 6/26/2023 at 8:17 PM LPN #12 progress note documented the resident was noted to be weak and lethargic. A 6/27/2023 at 3:32 PM LPN #8 progress note documented the resident had seizure activity for 5 minutes. The NP was made aware. A 6/28/2023 at 12:24 PM NP #3 progress note documented they evaluated the resident after having seizure activity on 6/27/2023. Progress notes reflected recent fatigue and somnolent effect. The plan was to decrease Seroquel from 200 mg twice daily to 150 mg twice daily. Staff reported the resident was going days without sleeping, and it was unknown if this was the root of the lethargy or if it was related more to increases in Seroquel over the past months. A 6/28/2023 NP #3 order documented Seroquel 150 mg twice daily at 9:00 AM and 9:00 PM; and Seroquel 200 mg give as one dose. There was no documentation reflecting the purpose of Seroquel 200 mg to be given as a one time dose. The 6/2023 Medication Administration Record (MAR) documented Seroquel 200 mg as a one time dose with a start date of 6/28/2023, and Seroquel 150 mg twice daily at 9:00 AM and 9:00 PM. The MAR documented: - on 6/28/2023 the 200 mg dose of Seroquel was administered by LPN #5 at 9:00 PM. The 150 mg dose of Seroquel was not administered. LPN #5 documented a one-time dose of Seroquel 200 mg was given. - on 6/29/2023 and 6/30/23 LPN #5 documented the resident was administered both 200 mg of Seroquel and 150 mg of Seroquel at 9:00 PM. The 7/2023 MAR documented: - on 7/1/2023 and 7/2/2023 LPN #6 documented the resident was administered both 200 mg of Seroquel and 150 mg of Seroquel at 9:00 PM. - on 7/3/2023 LPN #12 documented the resident was administered both 200 mg of Seroquel and 150 mg of Seroquel at 9:00 PM. - on 7/4/2023 LPN #7 documented the resident was administered both 200 mg of Seroquel and 150 mg of Seroquel at 9:00 PM. - on 7/5/2023 LPN #13 documented 200 mg of Seroquel was not administered at 9:00 PM and was discontinued. - on 7/6/2023 LPN #7 documented 200 mg Seroquel was not administered at 9:00 PM and was held per physician order. There was no corresponding physician order to discontinue Seroquel 200 mg at 9:00 PM and no progress notes documenting the resident received additional 200 mg doses of Seroquel for 6 days. Seizures and Blood Glucose The CCP, effective 6/29/2023, documented the resident had a seizure disorder and was maintained on anti-seizure medication. Interventions included obtain seizure history, if possible, to identify prodromal (early warnings of a seizure) symptoms, monitor drug treatment and dosage adjustments to minimize adverse reaction to other medications, monitor for complications caused by involuntary movement such as injury from falls or aspiration, monitor and report to medical the intensity and duration of seizure activity, and monitor labs as ordered, A 6/27/2023 at 3:32 PM LPN #8 progress note documented at 3:08 PM the resident presented with seizure activity for 5 minutes. Vital signs were taken, and the NP was made aware. A 6/28/2023 at 12:24 PM NP #3 progress note documented the resident was reported to have seizure activity the previous afternoon. The resident was back to baseline currently. The family member was spoken to and told the NP the resident had stopped seeing a neurologist. The NP advised on the importance of seeing a neurologist especially with the uptick in recent seizure activity. The family member stated they would think about a provider. A 6/28/2023 at 2:46 PM NP #3 order documented diazepam 12.5 mg-15 mg-17.5 mg-20 mg rectal kit. Apply 12.5 mg by rectal route once daily as needed for seizure. Call 911 if seizure lasts more than FIVE minutes. A 7/4/2023 at 11:27 AM LPN #8 progress note documented at 11:05 AM the resident was noted having a seizure lasting 10 minutes. Oxygen (O2) was applied, and the resident had an open area inside their lower left lip with scant bleeding. A 7/4/2023 at 12:17 PM LPN #11 documented they received a call from a certified nurse aide (CNA) that the resident was having a seizure at 11:06 AM. On arrival an LPN was with the resident, who was lying on their left side, eyes rolling, pallor in color, and pupils dilated. Postictal (after seizure) O2 was applied at 2 liters via a nasal cannula. The registered nurse (RN) on call was notified. NP #14 was notified and CBC (complete blood count), CMP (comprehensive metabolic panel), urinalysis, and valproic acid (seizure medication level) were ordered. Check vital signs every 4 hours for 24 hours and continue 2 liters of O2 for comfort. The 7/2023 MAR documented diazepam 12.5 mg-15 mg-17.5 mg-20 mg rectal kit. Apply 12.5 mg by rectal route once daily as needed for seizure. Call 911 if seizure lasts more than FIVE minutes. There was no entry for 7/4/2023. There was no documented evidence the resident was administered diazepam rectally or that 911 was called for the seizure lasting greater than 5 minutes on 7/4/2023. The 7/4/2023 at 12:48 PM laboratory result documented the resident's glucose was 46 mg/dl (normal 70-99 mg/dl). Alerted critical result to registered nurse (RN) Unit Manager #20 at 3:14 PM. There was no corresponding nursing progress note addressing the critical glucose result. A 7/5/2023 at 9:49 AM NP #3 medical order documented if resident experienced a seizure/seizure like activity, the RN/LPN must check blood glucose immediately and record result. Medicate with emergency glucagon (used to increase blood glucose) for any reading below 70. Follow normal hypoglycemia protocol as set forth by the facility. A 7/5/2023 at 10:53 AM NP #3 medical order documented finger sticks before meals and at HS (hour of sleep). Call medical provider for blood sugars (BS) less than 70 mg/dl and greater than 400 mg/dl everyday at 8:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM. A 7/5/2023 at 1:35 PM LPN Manager #9 progress note documented the resident was seen by the medical provider and new orders for finger sticks before each meal. The 7/2023 MAR documented finger sticks before meals and at HS (hour of sleep, bedtime). Call medical provider for blood sugar less than 70 mg/dl and greater than 400 mg/dl with a start date of 7/5/2023. On 7/7/2023 LPN #13 documented the resident's blood sugar was 64 mg/dl at 8:00 AM. There was no documented evidence the medical provider was contacted regarding the fingerstick result of 64 mg/dl. During an interview on 9/14/2023 at 3:47 PM, LPN #8 stated they were not aware the resident had a history of seizures and they had not received any records from the previous facility until 2 weeks after the resident was admitted . They witnessed the resident seizing on 2 occasions. They stated the first one they were alerted by a recreation aide that the resident was having a seizure. They made sure the resident was safe, turned them on their side, and called the Supervisor who took over. LPN #8 stated the Supervisor was probably an LPN but did recall who. After the first seizure, the NP addressed the situation with the LPNs and said if the resident continued to seize to call 911. They stated when the second seizure occurred the resident had been sleeping in a recliner in a common area. They stated they saw the resident's leg move oddly and had not seen this before. They looked closer and the resident's body was rigid with repetitive movements. They made sure the resident was safe and then alerted staff around the nursing station and called the Supervisor. The Supervisors responded and they thought they were the Nurse Managers from different floors. Once they arrived, LPN #8 went on to complete other duties. LPN #8 stated they were not aware of an order for rectal diazepam or to call 911. They stated if they were aware of the order, they would have used it. They stated 911 was not called. They stated communication of new orders was inconsistent and if they happened to be working they would know of new orders, otherwise they might not. They did not recall the resident having any seizures after that date. They stated they expressed to the NP and other nurses that the resident was very lethargic. They were aware of the 9:00 PM Seroquel order. If the order documented to give one time it meant only that one dose and not routinely. They stated if they saw that order, they would have questioned it. During an interview on 9/15/2023 at 11:47 AM, LPN #6 stated the resident was very active but they never saw aggression. They did not remember if there was a dosing change with the resident's Seroquel, but the medical staff had been talking about it. If an order was written to give as one dose it meant that only dose would be given, and it would not be continued. There should not have been additional doses in the medication cart in the resident's drawer if it was a one-time dose. There should have been Xs on the MAR after the one dose was given so it could not be given again. The LPN stated they never had an issues with the resident's finger sticks and they were always within normal limits. If the results were outside the parameters, they would call the provider for further guidance. They stated if the resident had a seizure, they would check the orders to see if anything was prescribed and would write a nursing note. During an interview on 9/18/2023 at 2:25 PM, LPN #13 stated they did not remember very much about the resident. Finger sticks were done before breakfast. They did not remember the resident having a low fingerstick of 64 maybe a 70 or something like that. They stated they would give them juice or something. If there was an order to call the provider for a result under 70, they would report it to the Nurse Manager who would text the provider. If a Nurse Manager was not available, they would notify the provider themselves and would write a note or put it on 24 hour report. During an interview on 9/20/2023 at 11:10 AM, NP #3 stated they consulted with the psychiatrist and discussed the resident and the Seroquel orders. They had done a gradual dose increase due to behavioral symptoms that were endangering the resident and others. They started noticing increased somnolence with the resident, so they backed up the dose. They recalled the 200 mg dose at 9:00 PM on 6/28/2023 was only supposed to be a one-time dose and was not intended to be routine. They stated 350 mg of Seroquel was considered an excessive dose and could cause lethargy and somnolence. Nursing reported breakthrough seizures on 6/28/2023 and they ordered the diazepam per rectum as needed. The diazepam should have been administered on 7/4/2023 when the resident had a seizure. A prolonged seizure could lead to coma or death. They stated it was not communicated to them the diazepam had not been administered as ordered. NP #3 stated after the 7/4/2023 seizure they ordered multiple labs and it came back with a blood glucose result of 46 mg/dl so they immediately ordered hypoglycemia protocols because low glucose could contribute to seizures. The nursing staff did not want to do the finger sticks because they said there was no reason to do them. NP #1 stated the finger sticks were necessary. If the fingerstick was below 70 mg/dl they should have called the NP and the resident should have had glucagon. The nurse should also recheck the fingerstick after giving the glucagon. They stated they were not aware the resident had a fingerstick reading of 64 mg/dl on 7/7/2023. They stated they attended morning report every day and always made clear what their treatment intentions were for residents. During an interview on 9/20/2023 at 1:00 PM LPN Unit Manager #9 stated the resident was receiving Seroquel for their behaviors which included aggression toward others. They stated when a medication was ordered a one-time dose it meant they should only be given the medication once. The resident likely had the one time ordered because of aggression. They stated they were not aware the resident received the one-time 200 mg dose of Seroquel in addition to the routine 150 mg dose on multiple days. LPN Unit Manager #9 stated the resident had a history of seizures and they would put the resident back to bed or in a chair, contact the family and the NP if they noted a seizure. If the resident had an order for Ativan for seizures it would be the responsibility of the medication nurse to administer it. Either the medication nurse or RN should have called 911 if it was an order. They stated the medication nurse was responsible for obtaining fingersticks, and would be responsible for calling the provider if the result was outside the parameters or they could call the nursing Supervisor on duty. If the finger stick was 64 mg/dl, LPN #13 should have notified the RN, LPN Manager, and the NP. They stated if LPN #13 had notified them they would have written a progress note. During an interview on 9/20/2023 at 3:49 PM, LPN #5 stated Seroquel was used for impulsive behaviors, but they were not sure if the resident received an antipsychotic medication. The resident exhibited behaviors including hitting and throwing objects. They stated they would try to redirect the resident, but they would do it all over again. LPN #5 stated they did not notice the resident to be lethargic during their stay. They stated they did not remember why the resident was ordered a one-time dose of Seroquel, but the resident needed it because of their behaviors. 10NYCRR415.12

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

Administration (Tag F0835)

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 the abbreviated survey (NY00322111), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #4). Specifically, facility Administration, including the Director of Nursing (DON) did not ensure residents were free from neglect, did not complete a thorough investigation into resident neglect, did not ensure staff were removed from having access to residents while neglect investigations were pending, and did not report neglect as required to the New York State Department of Health (NYS DOH). Findings include: Refer to F600 - Free From Abuse and Neglect On [DATE], Immediate Jeopardy and Substandard Quality of Care (SQC) was identified during an abbreviated complaint survey. Concerns rising to the level of immediate risk to resident health and safety included the facility's failure to provide services on [DATE] that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Surveillance video of the nursing unit from [DATE] at approximately 7:38 PM, revealed a resident falling backwards off a partition (separating the dining room from the hallway) that was approximately 27 inches in height and hitting their upper back on the floor in the hallway. The resident remained on the floor for approximately two and a half hours while 5 certified nurse aides (CNAs #1, 16, 17, 18, and 26), 1 licensed practical nurse (LPN #5), 1 resident helper (resident helper #27), and the housekeeper (housekeeper #47) walked by the resident without attending to the resident and without notifying a registered nurse (RN Supervisor #4) to complete an assessment. After approximately 2 hours, the resident unsuccessfully attempted to get up and tipped over twice. Shortly thereafter, the resident got themselves into a kneeling position and attempted to use the handrail to stand and fell over. This occurred 3 more times until 10:20 PM when CNA #17 and resident helper #27 transferred the resident into a wheelchair (without RNS #4 present for an assessment). RNS #4 arrived on the unit several minutes after the resident was transferred to the wheelchair and shortly thereafter pronounced the resident deceased . Furthermore, the facility failed to report the incident as required. Refer to F610 - Investigate/Prevent/Correct Alleged Violations Resident #4 was found on the floor by staff on [DATE] and remained on the floor without a registered nurse (RN) assessment for approximately 2 and a half hours and when the resident was assisted off the floor, they expired shortly thereafter. The facility's investigation was not thorough and complete as it did not: - identify neglect occurred when 5 certified nurse aides (CNAs #1, 16, 17, 18, and 26), 1 licensed practical nurse (LPN #5), 1 Resident Helper (Resident Helper #27), and 1 housekeeper (housekeeper #47) walked by the resident for approximately 2 and a half hours without attending to the resident and without notifying a registered nurse (RN) for an assessment and when the resident was assisted off the floor without an RN assessment by Resident Helper #27. - Identify or address discrepancies in CNA #1's statement when compared with video surveillance. - Attempt to identify a person seen (just off of camera view) interacting with the resident when the resident was attempting to stand unsuccessfully, and they did not provide assistance to the resident. - Address the resident's fall and subsequent death (approximately 2 and a half hours later) and did not rule out abuse/neglect related to the resident's death. Additionally, the facility did not protect residents from further potential neglect while the investigation was pending and did not report to the NYS DOH when abuse/neglect was not ruled out. During an interview on [DATE] at 11:10 AM, nurse practitioner (NP)) #3 stated they were notified on [DATE] that the resident expired. NP #3 watched the video from the nursing unit on [DATE] with former Administrator #49 and the Chief Executive Officer (CEO). They saw the resident fall and did not know if they struck their head. The video was long, so they did not see the whole thing. After watching the video, the NP told former Administrator #49 and the CEO their concern was the time lapse of the resident being on the floor with no one assisting them. During an interview on [DATE] at 9:00 AM, the CEO stated they did not have a hands-on role in investigations. In this case, there was a discussion on [DATE] and since they had access to the video, they pulled the video and Former Administrator #49, and the DON watched it as they were responsible for the investigation. Former Administrator #49 watched the video, and the DON was in and out of the office when it was playing. Former Administrator #49 and the DON told the CEO they were interviewing everyone involved and the CEO would not have a role in reviewing staff statements. The CEO stated they were not medical, but the resident fell and was on the floor for quite some time. Former Administrator #49 did not see the video as alarming, but the concern was that people were walking by the resident when they were on the floor. During an interview on [DATE] at 5:00 PM, the DON stated they completed all aspects of the incident investigation process including reviewing all reports, updating care plans, and ensured investigations were complete. The DON, former Administrator #49, the CEO ruled out abuse/neglect and determined what was reportable to the NYS DOH. The DON completed the investigation into the resident being on the floor on [DATE] and found that at least 3 staff members told licensed practical nurse (LPN) #5 the resident was on the floor and LPN #5 never checked on the resident. LPN #5 was re-educated as they did not have the resident assessed when they were on the floor. The DON did not review the entire video from [DATE]. They could not access video footage on their own and the CEO and former Administrator #49 watched it and typically, former Administrator #49 reported to the DON what they saw or would have the DON watch certain portions of video. The DON watched about 12 minutes of the video and did not see the resident fall, nor were they told the resident fell. They were not aware the resident was assisted off the floor by Resident Helper #27. The DON did not investigate the resident's death because they did not think the death was related to a fall and they could not determine if the resident fell. They stated they saw the resident on the floor, rolling and sitting. They mostly saw the portions of the video with LPN #5 as they were responsible for the re-education of LPN #5, and they were not told by former Administrator #49 that the resident fell. Former Administrator #49 was called for an interview on [DATE] and did not reply to the message. 10NYCRR 415.26(a)

Mar 2022 10 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · 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 the recertification and abbreviated (NY00277399 and NY00257605) surveys conducted from 3/1/22-3/8/22, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents reviewed (Resident #79). Specifically, Resident #79 was admitted and assessed as mild risk for developing pressure ulcers and had a deep tissue injury (DTI, deep red, maroon, purple discoloration) to their coccyx (tailbone) that was not routinely monitored and developed into a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. This resulted in harm to Resident #79 that was not immediate jeopardy. Findings include: The facility policy Wound/Wound Assessment dated 12/2021 documents all admissions will have a skin assessment. Residents admitted with an injury such as hematomas (pooling of blood under the skin), rhabdomyolysis (a breakdown of muscle tissue), and all other injury diagnosis will be monitored for pain, and once skin opens it will be considered a wound. Any wounds needing treatment the [physician] will be notified for orders. Once a week, full body surveillance may be done during bath time. Any new marks will be reported to the licensed practical nurse (LPN) for follow up and a registered nurse (RN) assessment to be done. The facility policy Prevention and Treatment of Pressure Ulcers dated 2/22 policy documents the purpose was to assess skin conditions and contributing factors, and to implement protocols to prevent threatened skin areas. Full body surveillance will be done on shower days. Any new marks or changed areas will be reported to the LPN for follow-up and a RN assessment will be done. When the completed shower sheet had noted changes, the LPN will notify the RN and these changes may be on 24-hour reports. The National Pressure Injury Advisory Panel (NPIAP) dated 2016 documents deep tissue pressure injury as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration. Resident #79 had diagnoses including sacral (a triangular bone at the base of the spine) fracture and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). The 1/7/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 for bed mobility, transfers, and toileting, extensive assistance of 1 for locomotion, dressing, hygiene, and bathing, was at risk for the development of pressure ulcers, did not have pressure ulcers, had a non-surgical dressing, was on a turning and positioning program and had pressure reducing devices for bed and wheelchair. The 12/31/21 RN Unit Manager #2 admission Nursing Form documented the resident had a red and bruised area on the coccyx. The Braden (measures risk of developing pressure ulcers) scale documented the resident was a mild risk for skin breakdown. The 12/31/21 comprehensive care plan documented the resident was at risk for skin breakdown and for falls. Interventions included utilize pressure reducing devices, provide assist with bed mobility, transfer with staff assist, complete pressure ulcer risk assessment (Braden Scale) quarterly and as needed, certified nurse aide (CNA) report on skin condition daily during care and report any skin abnormalities to nurse, provide pressure reducing mattress, use pressure reducing cushion in wheelchair, maintain turning and positioning schedule every 2-4 hours and as needed with staff assist, prevent friction during transfers, use skin protectant/skin barrier when performing perineal care, off load heels while in bed, anticipate needs, use proper footwear, ensure call bell in reach at all times, and maintain safe environment. The 1/18/22 at 2:37 PM RN Unit Manager #2 progress note documented the family wanted the resident sent to the hospital for dehydration. The physician was made aware and ordered the resident be sent to the hospital. The resident was hospitalized from [DATE]-[DATE]. The 1/19/22 updated comprehensive care plan (CCP) documented the resident as at risk for skin breakdown. Interventions did not include goals, interventions, or notes for skin breakdown. The 1/24/22 hospital discharge summary documented the resident was to be discharged back to the facility. The resident was admitted to the hospital for bladder distention. An indwelling urinary catheter was inserted. The discharge summary did not document a dressing or treatment to the coccyx area. The untimed Nursing admission Assessment form created by RN Unit Manager #2 on 1/24/22 and completed 2/8/22 documented the resident's general skin condition was pale and dry with no edema (swelling). The resident had a bruise on the coccyx/sacral area, was chair fast, had very poor nutrition, and was a moderate risk for skin breakdown. The resident's skin was clean, dry, and intact. The 1/24/22 at 5:32 PM RN Supervisor (RNS) #9 progress note documented the resident had a new dressing to the coccyx that was undated upon return from the hospital at 4:06 PM. The surrounding skin was intact and blanchable. The resident had bruising to several areas including the left hip, lower back, left hand, and right wrist which were apparent IV sites. The resident also had bruising to the right ankle and right small toe. There was no further documentation describing if the coccyx dressing was removed or an assessment of the underlying area. The 1/24/22 re-admission Braden scale completed by RN Unit Manager #2 documented the resident was at mild risk of developing a pressure ulcer. The 1/24/22 physician order documented ice to the sacrum as needed (prn) for pain. The 1/24/22 updated CCP documented the resident had a sacral fracture and was at risk for skin breakdown. Interventions included comfort measures, provide pain medications as ordered, utilize pain scale, reposition every 2 hours and as needed, adaptive devices as directed, assist with transfers, and utilize pressure relieving devices. The CCP documented staff were to complete Braden scale quarterly and as needed, CNA report of skin condition daily during care and report any skin abnormalities to a nurse. Additionally, staff were to provide pressure reducing mattress, pressure reducing device in wheelchair, turn and position every 2-4 hours with staff assistance, use skin protectant/skin barrier during perineal care, document any pain, and their fracture was to be followed by the orthopedic physician. The treatment administration record (TAR) documented ice to sacrum prn was not administered in 1/2022 or 2/2022. There was no documentation between 1/24/22-2/15/22 the resident's coccyx was monitored or assessed. The 2/15/22 at 6:36 AM RNS #8 progress note documented the resident had a dirty dressing covering the sacral area. The LPN removed the dressing and underneath was a large, reddened area that looked like it was filled with grayish silly putty in the shape of a hook. The LPN cleaned it and put a covering on it. The area would be seen by the skin team and the resident was not complaining of pain. The 2/16/22 at 11:33 AM Wound RN #7 progress note documented the resident had an unstageable (full thickness tissue loss in which the base of the ulcer was covered by dead tissue) area on the coccyx measuring 4.5 centimeters (cm) x 3.0 cm, was to have no brief on in bed, had an alternating air mattress and a ROHO cushion (both pressure relieving devices). The treatment was Santyl (used to remove dead tissue) and back to bed after meals. The note documented the resident had a noticeable decline. The 2/16/22 updated CCP documented the resident had an unstageable pressure ulcer on the coccyx. Interventions included treatments as ordered, assess during treatments and document weekly. Staff were to put the resident back to bed after meals, consult with the dietitian as needed, and turn and reposition every 2 hours as recommended. The CCP documented to monitor for infection, perform wound care rounds weekly, provide ROHO, alternating air mattress, and weekly wound measurements. The 2/2022 TAR documented on 2/16/22 at 12:11 PM, a new order to cleanse open area (did not specify location) with normal saline (NS), pat dry, apply Santyl to wound bed, cover with border foam dressing daily and as needed. The 2/18/22 at 3:38 PM registered dietitian (RD) #25 progress note documented the resident had a new unstageable pressure ulcer to the coccyx and refer to the weekly wound RN note on 2/16 for details. The 2/21/22 Wound RN #7 initial skin assessment of new area documented the resident had an unstageable pressure ulcer on the coccyx measuring 4.3 centimeters (cm) x 3.0 cm. The TAR documented on 2/18/22 at 11:37 AM, cleanse open area with NS, pat dry, apply Santyl to wound bed then crushed Flagyl tab (antibiotic), cover with border foam dressing daily and prn. The 2/22/22 at 1:51 PM Support RN #3 progress note documented family was made aware of the area on the coccyx when the resident returned from the hospital and had become a wound. The facility was treating the wound and the wound care team was following. The 2/23/22 at 11:57 AM RN Unit Manager #2 note documented skin rounds were done and the deep tissue injury (DTI) to the sacrum had now opened and measured 4.0 cm x 4.0 cm with a 2.0 cm tunnel at 12 o'clock with clear view of the sacral bone. The family was made aware, and the resident was to be sent to the wound clinic for evaluation. The 2/23/22 physician order documented cleanse open area with NS, pat dry, NS to roll gauze and gently pack at 12 o'clock area and roll out to cover lower portion of wound cover with border dressing. The 2/23/22 at 1:01 PM Wound RN #7 progress note documented the resident now had a Stage IV pressure ulcer on the coccyx measuring 4.0 cm x 4.0 cm with a 2.0 cm tunneling at noon position. On re-admission a RN noted a deep tissue injury in the area. Treatment was NS gentle packing and cover. The facility was to set up a wound clinic appointment. The 2/24/22 at 3:28 PM Wound RN #7 progress note documented the resident had an unstageable pressure ulcer on the coccyx measuring 4.5 cm x 3.0 cm. The resident was to have no brief in bed, and an alternating air mattress and ROHO cushion. The treatment was Santyl and back to bed after meals. The 2/28/22 physician note documented the resident had a history of sacral fracture, they were told the resident had rhabdomyolysis that was corrected, and the resident had a second hospitalization. When coming to the facility for the first time, the resident had a sizable bruise over the sacrum that later opened and basically exposed a sacral Stage IV decubitus (pressure ulcer) which could be very difficult to heal since there was not much viable tissue over the large area and a very deep space. During an observation of a treatment with LPN #6, RN Unit Manager #2, and Wound RN #7 on 3/3/22 at 2:24 PM, RN Unit Manager #2 and Wound RN #7 rolled the resident to the left side. Wound RN #7 removed the old coccyx dressing. LPN #6 cleansed the wound with NS. The wound was about 4 cm x 4 cm x 2 cm with tunneling at 12 o'clock and the wound was pink with granulation. The wound was packed as ordered, covered with a border dressing, and the dressing was dated. When interviewed on 3/4/22 at 4:17 PM, RN Unit Manager #2 stated the 1/24/22 admission skin assessment documented the deep tissue injury as a bruise. The area was unstageable, and staff could not see below the intact outer skin. RN Unit Manager #2 stated the resident was initially admitted with the same area due to a fall prior to admission. The bruise was later classified as a deep tissue injury. The RN expected CNAs to observe the area during care and report any changes or abnormalities to the nurse. The 3/7/22 at 3:21 PM Support RN #3 progress note documented a 2/16/22 follow up report from the 11-7 nurse who worked 2/15/22 into 2/16/22. The resident had a pressure ulcer to the coccyx and was added to wound rounds. Staff were to continue to monitor. When interviewed on 3/7/22 at 11:23 AM, CNA #5 stated the resident could not reposition themself in bed since returning from the hospital, so staff were repositioning the resident every couple of hours. The CNA stated CNAs were not able to make notes in the electronic record, only document that care was done or not done, and were to report any abnormal findings to the nurse for documentation. The CNA remembered a sacral dressing prior to mid 2/2022 and that it had never been observed to be dirty. When interviewed on 3/7/22 at 11:51, RNS #9 stated they did not remember working the day their note was written on 1/24/22 and did not remember assessing the resident upon return from the hospital. When interviewed on 3/7/22 at 12:26 PM, LPN #6 stated only the RNs were allowed to complete assessments. LPN #6 stated they did not remember the resident having a coccyx dressing and would have noted it if they did. Upon return from the hospital, the resident had a reddened area that staff were putting barrier cream on to prevent further breakdown. The LPN stated no CNA asked the LPN to look at the coccyx area prior to the resident's coccyx area opening to a Stage IV pressure ulcer. When interviewed on 3/7/22 at 12:28 PM, RN Unit Manager #2 stated the resident continued to have the coccyx bruise upon return from the hospital. The facility did not track bruises on pressure areas, was not aware the resident returned from the hospital with a dressing to that area, and staff were applying barrier cream to prevent the bruise from deteriorating. When interviewed on 3/7/22 at 12:30 PM, Wound RN #7 stated the facility did weekly wound rounds and did not observe bruises. Wound RN #7 stated a DTI looked like a bruise and the extent of injury was unknown until the area opened. The resident had the coccyx bruise upon initial admission and was not identified as a DTI until the area opened on 2/16/22. A resident with a bruise was looked at daily by unit staff during care but would not be formally tracked. Unit staff should alert the nurse with any changes in the bruise. The CNAs should have alerted a nurse for assessment if the resident had a coccyx dressing. The RN was expected to write a progress note regarding the area with the dressing. The wound nurse would be made aware if the area under the dressing was open. Wound nurse #7 stated RN Unit Manager #2 was aware of the resident's comorbidities and coccyx bruise. The resident's comorbidities contributed to the bruise developing into a Stage IV pressure ulcer and the facility should have tracked the bruise closer in hindsight. When interviewed on 3/7/22 at 12:54 PM, physician #32 stated they were made aware of the Stage IV coccyx area after it opened. The area manifested as a closed bruise, staff were unable to assess what was under the closed skin, and the facility did not track bruises. The physician stated a different treatment would have been ordered if they knew the area would open to a Stage IV wound. When interviewed on 3/8/22 at 10:43 AM, the agency physician assistant (PA) stated the resident was not under their care. The PA had not seen the resident's coccyx wound, but due to the resident's multiple comorbidities and the area being on a pressure area, they would have monitored it more closely. When interviewed on 3/8/22 at 11:24 AM, the Director of Nursing (DON) stated bruises on pressure areas were not tracked by the facility. A skin assessment was to be done by a RN on the day of admission/readmission and all dressings should be removed to assess the area underneath unless there was a physician order not to do so. Staff were aware the resident had a bruise on their coccyx but were unaware of the dressing on readmission as the RN #9's progress note did not appear on the 24-hour report as it should have. The DON stated nurses do not assess a resident's skin weekly unless asked to by a CNA. The DON expected the CNA to notify the RN if there was a new or dirty dressing on a resident. It was expected that the RN remove the dressing, assess the area, and document it in a progress note. The DON stated RN Unit Manager #2 informed her there was no dressing and a bruise on the resident's coccyx on admission. The resident did not have a physician's order for the dressing at any time prior to 2/15/22. The DON expected CNAs to perform daily skin checks during care and report abnormal findings to the nurse. The DON stated staff were unsure if the dressing from re-admission on [DATE] was the same as the dirty dressing found on 2/15/22 as there was no documentation of a coccyx dressing between those dates. There was no investigation done on the dirty dressing found on 2/15/22 as staff were not aware of the reported 1/24/22 coccyx dressing. The DON stated there should have been follow up to the 1/24/22 dressing and why it was in place on readmission. When interviewed on 3/8/22 at 1:09 PM, Wound RN #7 stated they were unsure how long the dressing found on 2/15/22 was on the resident. The resident should have had an order for a coccyx dressing. When interviewed on 3/8/22 at 02:34 PM, physician #32 stated the resident was assessed by them on 1/25/22 and the bruise was not looked at. The bruise was not checked by the physician with subsequent visits as they did not assess bruises unless asked by staff. The resident was placed on wound rounds once the bruise opened. 10NYCRR 415.12(c)(2)

CONCERN (D)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected 1 resident

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Based on observation and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction with respect to the facility. Specifically, the facility did not post the survey results and plan of correction from the most recent Life Safety Code Federal survey conducted on 9/11/19. Findings include: During observations on 3/1/22 at 2:50 PM and 3/2/22 at 9:15 AM, the survey result binder located next to the front desk included the results from the 9/11/19 Federal Health Recertification Survey. The results from the 9/11/19 federal Life Safety Code Survey and the corresponding plan of correction was not included inside the binder. During an interview on 3/2/22 at 5:37 PM, the Administrator stated that the plan of corrections for the Health Recertification Survey and the Life Safety Code Survey from the last federal survey in 2019 were posted in a binder near the front desk. They stated that these results were required to be publicly posted. The Administrator stated any person could have taken these results out of the binder. The Administrator stated the Life Safety Code Survey plan of correction from 2019 had been placed in the binder after that survey. During an observation on 3/2/22 at 5:40 PM, with the Administrator present, the survey result binder located next to the reception desk included the results from the 9/11/19 Federal Health Recertification Survey. The results from the 9/11/19 Federal Life Safety Code Survey and the corresponding plan of correction was not included inside the binder. During an interview on 3/3/22 at 10:54 AM, the Administrator stated when the binder was last checked in 12/2021 all required documentation was there. They stated previous survey results were required to be posted so families and residents could have full knowledge of all plans of correction. The Administrator stated resident families were told on admission they could access the facility's plan of correction online for the last three years. The Administrator stated they were responsible for ensuring the results were publicly posted and the survey result binder located near the front desk was the only location for the public to view this information. 10NYCRR 415.3 (c)(v)

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to ensure that when a restraint was indicated, the least restrictive alternative for the least amount of time was used and included ongoing re-evaluation of the need for the restraint for 1 of 2 residents (Resident #48) reviewed. Specifically, Resident #48 had an alarming wheelchair seat belt that was not assessed to determine if it was the least restrictive device, and a plan was not implemented to ensure the device was used for the least amount of time. Findings include: The facility Restraint Policy dated 11/2021 documents it was the policy of the facility to promote restraint reduction to ensure greater functional independence and a less restrictive environment, while ensuring resident safety. If a resident can tell you why the safety measure is in place and they can release restraint, it is not considered a restraint. If resident has a noted change in condition and can no longer recall, care plan and CNA sheets will be updated, and it would now be treated as a restraint. The resident using restraints shall be assessed at least quarterly. Procedure for reduced use of restraint includes, This must be on [care plan] for all residents with restraint. The restraint may be removed for meals, and the resident must remain in direct view of staff when off. Restraint may be removed while family/visitors are present. The restraint may be removed at supervised activities. Resident #48 had diagnoses including anxiety disorder and dementia. The 1/13/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, had no behavioral symptoms affecting self or others, required extensive assistance with most activities of daily living (ADLs), did not have any restraints and used chair alarms. The 2/5/21 comprehensive care plan (CCP) documented the resident had a potential for falls. The CCP was updated on 4/7/21 by registered nurse (RN) #2 and documented a wheelchair safety belt was added to help remind the resident to ask for help when standing. The resident was able to open and close the clasp of the safety belt. There was no documented evidence the resident was assessed to determine if the seat belt was the least restrictive device and the seat belt was used for the least amount of time possible. The care instructions active in 3/2022 documented the resident had a seat belt alarm. There were no directions on the application and use of the seat belt. The resident was observed seated in a manual wheelchair wearing an alarmed seat belt; - on 3/2/22 at 10:05 AM seated in the lounge. - on 3/4/22 at 10:48 AM-11:45 AM seated in the lounge. - on 3/4/22 at 12:23 and 1:01 PM seated at a dining table eating lunch. - on 3/4/22 at 1:36 PM seated in the lounge area with their head down on the table. - on 3/7/22 at 9:10 AM while eating breakfast in the dining room. During an interview with certified nurse aide (CNA) #1 on 3/7/22 at 2:30 PM, they stated the resident would try to unbuckle the seat belt and stand from their chair. The seat belt was on the resident's waist and would pull the resident back down into their chair. The resident could not follow directions to unbuckle the belt and did not understand why they had the buckle as they had a diagnosis of dementia. The resident was unable to hold a conversation and did not respond appropriately to questions. The CNA stated the seat belt had been in place a long time. The CNA stated the resident was to wear the seat belt at all times when out of bed. During an interview with RN #3 on 3/7/22 at 2:38 PM, they stated the resident had a seat belt alarm on their chair. They stated the resident was to have this when out of bed and seated in their chair. It was in place in case the resident tried to get out of their chair and to prevent falls. They stated it should have a restraint evaluation if it was considered a restraint for the resident. A seat belt would be considered a restraint if the resident was not able to release the seat belt and it should be re-evaluated every 90 days. The RN stated they were unable to find any restraint evaluations for the seat belt. They stated the resident may have been able to release and consent to the seat belt when it was first implemented. During the interview the RN asked the resident to release their seat belt and if the resident knew what it was for. The resident was unable to respond to either request. The RN stated the seat belt was not a restraint as it was used for the resident's safety. They stated if the resident had a decline in condition, they should have been referred to occupational therapy (OT) for re-evaluation of restraint use and this had not been done. During a combined interview with Support RN #3 and RN Unit Manager #2 on 3/7/22 at 2:56 PM, RN Unit Manager #2 stated the resident had been able to remove and explain use of the seat belt when it was implemented. RN Unit Manager #2 stated they had added the seat belt to the care plan in 4/2021. They stated the seat belt had been in place because the resident would attempt to self-transfer. A restraint decision tree form would not have been completed when the seat belt was implemented as the resident was able to release it on their own and knew why it was being used. If the resident was no longer able to do this, then the resident should be referred to OT for re-evaluation. If the seat belt was considered a restraint the decision tree would be completed and should include a release plan. The RN Unit Manager stated the resident had not had any referrals to therapy for the seat belt. During an interview with the Director of Rehabilitation on 3/7/22 at 3:28 PM, they stated the facility did not often use seat belts. They stated the resident was able to take the seat belt on and off when it was first implemented. At that time the resident was participating in therapy and frequently was trying to stand and would fall, so they implemented the seat belt. Once discharged from therapy it would be nursing's responsibility to monitor the use of the seat belt. If the resident had a change, nursing should put in a referral to therapy to have the seat belt re-evaluated. They stated they were not aware of any change in the resident, and they had not received any referrals. The Director stated given the resident's cognitive decline and inability to understand, a referral should have been made. 10NYCRR 415.4(a)(2-3, 5)

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 record review and interview during the recertification survey conducted 3/1-3/8/22, the facility failed to ensure, to the extent practicable, the participation of the resident and the resident's representative in the development of the comprehensive care plan for 1 of 2 residents (Resident #50) reviewed. Specifically, Resident #50 was not invited and did not attend their comprehensive care plan meetings. Findings include: The facility policy Comprehensive Care Plans dated 11/2021 documents it is the policy of the facility to provide each resident with a Comprehensive Plan of care to assist the resident to attain or maintain their optimal, physical, mental, and psychosocial functioning. Social Services was to set up care plan meetings as needed, all care plans are reviewed at that time (families may join meetings via phone or face time, families are not required to attend, and residents are encouraged to attend). Families may request care plan meetings at any time. Resident #50 had diagnoses including depression and anxiety. The 1/6/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. The care plan activity report did not document attendance of the resident or the resident's family at care plan meetings after 2019. The comprehensive care plan (CCP) effective 2/12/20 documented the resident required adjustment to long term care. Interventions included remind the resident of upcoming events and keep the resident and the resident's family informed through team meetings and 1:1 updates. There was no documented evidence in interdisciplinary progress notes in 2020 or 2021, the resident was invited or attended a care plan meeting. During a Resident Council meeting on 3/3/22 at 10:05 AM, the resident stated they had not participated in a care plan meeting, and they would like to. During an interview with the Director of Social Services on 3/7/22 at 3:10 PM, they stated they were assigned to the resident's unit. They reviewed the resident's record and stated care plan meetings would have been held around the annual assessment dates of 5/7/20 and 4/29/21. They stated there was no documentation in the resident's medical record the resident was invited or attended care plan meetings. They stated the resident was alert and oriented and would participate in meetings if in attendance. They stated that it was social service's responsibility to invite the resident to meetings, they had not worked with the resident during those dates, and they did not know why the resident had not been invited. 10NYCRR 415.11(c)(2)(ii)

CONCERN (D)

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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Based on observation, record review and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Residents #100 and 253) reviewed. Specifically, Resident #100 did not receive toileting assistance; and Resident #253 was not assisted with care timely and did not have a care plan to address behavioral symptoms when requesting care. Findings include: The facility policy Toileting Residents dated 12/2018 documents the registered nurse (RN) will indicate the frequency in which the resident shall be toileted in [electronic medical record] and care plan. The time selected reflects the individual needs of the residents on a two (2) to four (4) hour basis and as needed basis (PRN) during the night. Certified nurse aide (CNA) assignment sheet, residents care plan and [electronic medical record] will reflect the resident's toileting needs. Staff will ensure adaptive equipment based on resident identified needs are available. 1) Resident #100 had diagnoses including Alzheimer's disease, constipation, and urinary tract infection (UTI). The 2/10/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance with toileting, was incontinent of bowel and bladder and was at risk for developing pressure ulcers. The comprehensive care plan (CCP) effective 6/2/21 documented the resident required assistance of 2 for toileting. The resident was incontinent of bowel and bladder and staff were to maintain a toileting schedule every 2 to 4 hours and as needed. The 2/28/22 care instructions documented the resident was to be toileted every 2 to 4 hours and as needed. The resident required assistance of 2 staff for transferring. The resident was observed on 3/4/22 at 10:03 AM, seated in a lounge area on the unit. There was a strong odor of feces that was not present prior to the resident's arrival to the lounge. Certified nurse aide (CNA) #18 brought the resident closer to the TV (nearer to the surveyor) and the odor of feces became stronger. The resident had a brown substance on their leg seeping from under their pant leg. At 10:26 AM, CNA #18 walked through the lounge area, went to linen closet near the resident, and left the area without checking the resident. At 10:28 AM, the same CNA walked through the lounge into another hallway. At 10:43 AM, CNA #17 came and assisted the resident to the shower room for toileting. On 3/4/22 at 12:03 PM, the activities of daily living (ADL) did not document that toileting care had been provided to Resident #100 for the 7:00 AM-11:00 AM shift. On 3/4/22 at 5:00 PM, and the 7:00 AM-11:00 AM shift, there was no documentation that toileting care had been provided on the 7:00 AM - 11:00 AM shift. During an interview and observation with CNA #17 on 3/4/22 at 10:43 AM, they stated they started working on the unit at 9:00 AM that morning. They were not sure what time the resident had last been toileted. The resident's used incontinence brief was observed, and the brief had a large amount of feces causing the brief to sag. The brief was full of feces, and there was dried feces on the inside of the resident's pants and on their ankles. The CNA stated they needed helped, as there was so much feces on the resident and in the brief, the resident would have to be showered. During a follow up interview with CNA #17 on 3/4/22 at 11:04 AM, they stated the CNA that worked before them did not report off on the residents and they did not know who needed to be toileted. They were not aware the resident was sitting in feces for 40 minutes and it was not dignified for the resident. The CNA stated the resident had a large amount of feces and some had been dried on. They stated it appeared the resident had not been toileted or changed in sometime and the resident was supposed to be changed every 2 to 4 hours and as needed. During an interview with CNA #19 on 3/4/22 at 10:49 AM, they stated they were assigned to the resident that morning and had provided care to the resident. They stated they last changed/toileted the resident at 8:30 AM and assisted them to their chair. The CNA stated they were just about to change the resident again when they had an assignment change. They let the oncoming CNA know the resident required assistance with changing. The CNA stated that 40 minutes was a long time to be sitting in a bowel movement with the feces seeping out and it was not dignified. During an interview with CNA #18 on 3/4/22 at 11:56 AM, they stated that they brought the resident to the lounge to sit down and did not notice any smell or observe any issues with incontinence. They stated CNA #17 came in to help during the morning shift, and they assisted CNA #17 with washing the resident in the shower. The resident had a large amount of feces, and it was dried and extended down their leg. During an interview with registered nurse (RN) Unit Manager #21 on 3/4/22 at 1:44 PM, they stated they had changed the CNA assignments that morning. The CNAs should have communicated to the person that was taking over about the residents they were caring for. Sitting in feces for that long could affect skin, and it was not dignified. The resident required changing every 2-4 hours. 2) Resident #253 had diagnoses including cerebral infarction (stroke), hypertension, and peripheral vascular disease (poor circulation). The 2/22/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, displayed physical behavioral symptoms towards others, and required extensive assistance of 2 for toileting. The comprehensive care plan (CCP) effective 2/15/22 documented the resident had an activities of daily living (ADL) deficit and required assistance of 2 for toileting and dressing. The resident was incontinent of bowel and bladder and was to maintain a toileting schedule every 2 to 4 hours and as needed. The 3/8/22 care instructions documented the resident required assistance with toileting. Staff were to transfer the resident with a sit to stand (mechanical lift) and toilet every 2-4 hours and as needed. The following continuous observations were made of Resident #253 on 3/3/22: - At 9:50 AM with their call light on, sitting in a recliner in their room and calling out for assistance. - At 10:00 AM, an unidentified staff member entered the room and turned the call light off, did not provide care, and left the room. - At 10:15 AM, yelling for help from their room, the call light was off, and no staff were observed in the hallway. - At 10:20 AM, licensed practical nurse (LPN) #16 entered the room and the resident stated they needed to use the bathroom. The nurse exited the room and went and asked the other LPN on the unit for assistance with the resident. LPN #16 did not return to the room. - At 10:56 AM, 2 unidentified certified nurse aides (CNAs) entered the resident's room with a sit to stand lift and closed the door. The resident was observed urinating in a urinal with assistance from the 2 CNAs. When interviewed on 3/7/22 at 4:41 PM, CNA #5 stated the resident required the use of a sit-to-stand lift and 2-3 staff. The resident should be checked every 2-3 hours, but each time staff left the room the resident would call out for help again. They stated the call light should be answered within 2-5 minutes, and it was not acceptable to wait 40 minutes. When interviewed on 3/7/22 at 5:04 PM, CNA #14 stated Resident #253 required the assistance of 2 staff with care. The resident often yelled out from their room, was impatient and would put the call light on shortly after staff exited the room. The call lights should be answered immediately and waiting 40 minutes would not be an acceptable time to wait to be assisted. When interviewed on 3/7/22 at 5:33 PM, LPN #15 stated if a resident was frequently calling for toileting assistance, and it was not the result of a physical condition, then it should be added to the care plan as a behavioral condition. The resident had called often for toileting assistance and sometimes voided very little. The resident was not care planned for this toileting behavior, but they should have been. When interviewed on 3/7/22 at 5:46 PM registered nurse (RN) Unit Manager #2 stated if a resident called frequently for toileting, they should have ruled out any physical reason why. If determined it was a behavior, then it should have been added to the care plan. The resident was admitted with many behaviors, and they were unaware that the resident had toileting behaviors. The nurse stated the resident was not care planned for this behavior but should have been. 10NYCCR 415.12(a)(3)

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

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 the recertification and abbreviated (NY00257605) surveys conducted 3/1/22-3/8/22, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents (Resident #97) reviewed. Specifically, Resident #97 had a significant weight loss without timely nutritional assessments and interventions, and weekly weights were not consistently obtained as ordered. Findings include: The facility policy Nutritional Assessment and Care Plan dated 12/21 documents all residents will receive a comprehensive nutritional assessment by a qualified professional (registered dietitian [RD] or dietetic technician). Assessment and documentation of nutritional concerns is documented and recorded in a timely manner in the medical record to ensure the provision and documentation of optimal nutritional care for all residents. Each assessment and care plan may include, but is not limited to, consideration of the resident's diet history, height and weight, functional status, medical and physical impairments, nutritionally significant medications, laboratory test results, food and fluid intake, counseling needs and discharge planning. All residents are assessed and documented at a minimum of 90 days and as needed; the frequency depends ultimately on the condition of the resident. The facility policy Resident Weight Monitoring dated 2/22 documents all residents with patterned or a significant weight change, which may indicate those residents are at a nutritional risk, will be assessed by the interdisciplinary team as indicated. Weights are to be obtained in the following manner: within 72 hours of admission to the facility, Nursing will weigh resident to establish a baseline weight which will be documented into the weight book; Nursing is responsible for weighing each new resident. Residents may be weighted more frequently, i.e., daily, every other day, weekly, etc. as determined by the physician/nurse practitioner, nursing and/or registered dietitian recommendation. Criteria for a re-weight may be used by Nursing if the resident has had a 3 pound (lb) weight loss or gain and weighs 100 lbs or less; or a 5 lb weight loss or gain and the resident weighs 100 lbs or more, unless otherwise directed by the MD (medical doctor, physician)/NP (nurse practitioner); all weights will be recorded in the EMR (Electronic Medical Record) on the shift they were retained. A re-weigh will be done at the dietitian's discretion and all residents plans for weights and re-weights are done resident specific. Resident #97 had diagnoses including dementia and depression. The 2/10/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required supervision/set up with eating, weighed 124 pounds (lbs) and had a significant non-physician prescribed weight loss. The 8/13/21 physician orders documented the resident was on a regular consistency diet with a plan for weekly weights. The 8/14/21 comprehensive care plan (CCP) documented the resident was at risk for weight loss. Interventions included monitor intakes and weights per physician order, offer alternates for dislikes or when 25% or less was eaten at meals, provide a regular liberalized diet, and update food preferences. The resident required set up with cues and hands on feeding assistance at meals. The 8/20/21 initial nutrition assessment by registered dietitian (RD) #26 documented the resident was admitted for palliative care with diagnoses of atrial fibrillation (abnormal heartbeat) and heart failure. The resident had made improvements in therapy and end of life medications were discontinued by medical. The resident continued on a regular diet, meal intakes averaged 61%, the resident weighed 152.7 pounds, family selected menus, the resident continued on weekly weights, and weight maintenance of 150-155 pounds was a goal. The weight record documented the resident weighed: - 152.7 lbs on 8/17/21 - 145.3 lbs on 8/24/21 (-4.85%/7.4 lbs loss in 1 week) - 146.7 lbs on 8/31/21 - 145.0 lbs on 9/13/21 - 144.8 lbs on 9/14/21 - 145.6 lbs on 9/21/21 - There were no documented weights between 9/21/21 and 10/13/21. - 138.6 on 10/13/21 (-9.23 %/14.1 lbs loss in 2 months) - 138.8 on 10/19/21 and 10/29/21 (-4.5%/ 6.8 pounds loss from 9/21/21). There was no documented evidence the resident was weighed weekly as ordered. There were no documented nutrition progress notes between 8/20/21 and 10/29/21 and no documented evidence the medical provider was notified of the resident's weight loss. A 10/29/21 RD #25 progress note documented the resident had an unplanned weight loss on 9/21/21, weighing 145.6 pounds and was weighed at 138.8 pounds on 10/19/21. This was 6.7 pounds/4.6% loss at one month. The weight was not significant. The resident's appetite had shown an increase and they were consistently consuming 75% of meals. The resident's family member continued assisting with menu selection to ensure food preferences were provided. Current intakes appeared to be adequate to meet estimated nutritional needs. The plan was to continue to monitor need for additional interventions. The 11/5/21 RD #25 progress note documented the resident weighed 138.8 pounds and appeared to have overall stabilized. The resident had variable intakes, and family member assisted with menu completion. Staff were to offer 240 milliliters of fluids with medication pass to promote optimal fluid intake. The plan was to continue to monitor. A 11/17/21 RD #25 progress note documented the resident weighed 138.7 pounds on 11/16/21 and the resident had stabilized. An 11/18/21 RD #25 assessment documented the resident had a 9.2 % loss at 3 months. The family member assisted with menu selection. The resident was independent with set up at meals. Weight showed stabilization over on month, following an unplanned weight loss. The resident weight record documented: - between 11/23/21 and 12/15/21 had documented weights between 138.5-138.9 lbs. - There were no documented weights between 12/16/21-1/10/22. - On 1/11/22, the resident weighed 138.5 lbs. - On 1/18/22, the resident weighed 140.0 lbs. - There were no documented weights between 1/19-2/7/22. - On 2/8/22, the resident weighed 124.3 lbs (-10.25%/14.2 lbs loss at 1 month; -10.45%/14.5 lbs loss at 3 months; 18.60%/28.4 pounds since 8/17/21). There were no documented nutrition progress notes or nutrition assessments between 11/19/21 and 2/9/22. The 2/10/22 RD #25 assessment documented the meal intake had insufficient documentation. The resident weighed 124.1 lbs at time of assessment, 140.0 lbs on 1/18/22, and 138.0 lbs on 11/16/21. The resident had a 18.7% weight loss at 6 months. The resident had a significant unplanned weight loss over the past month. The resident's Levothyroxine was adjusted related to an elevated TSH (blood test measuring thyroid stimulating hormone) of 18.4 on 2/7/22. The RD recommended weekly weights and weight stabilization was desired. If there were further weight loss, they would consider a nutritional supplement. The weight record documented the resident weighed: - 124.1 lbs on 2/15/21; and - 119.0 lbs on 2/22/22 (-15%/21 lbs loss at 1 month; -4.12%/5.1 lbs at 1 week). There were no documented nutrition assessments following the 2/22/22 weight loss through 3/1/22. The 3/1/22 RD #25 progress note documented to see the 2/18/22 RD note for significant weight loss. The resident weighed 119.0 pounds on 2/22/22, indicating further unplanned weight loss of 5.1 pounds in a week. Re-weight was requested and pending. The registered nurse (RN) was made aware. Meal consumption average was 61%. Recommended addition of 120 milliliters (ml) 2 cal HN (nutritional supplement) daily to add 237 Kcals (Kilocalories) and 10 grams (g) of protein. Continue weekly weights to monitor weight trends. The 3/2/22 RD #25 progress note documented the resident weight 128.2 which was a desired gain of 4.1 pounds. The plan was to continue weekly weights and adjust plan of care as needed. A physician's order on 3/2/22 included 120 ml of 2 Cal HN (nutritional supplement) once daily. The resident was observed on 3/2/22 at 2:03 PM, seated in the dining room. The resident was sitting at the table not eating. The resident had eaten 25% of their [NAME] sandwich, 25% of French fries, 50% of fruit cup, 100% water, 100% of coffee, and 50% apple juice. During an interview with certified nurse aide (CNA) #34 on 3/7/22 at 12:04 PM, they stated a CNA would know what residents needed to be weighed or re-weighed by reviewing the CNA assignment sheet. If a resident declined to be weighed, they would notify the licensed practical nurse (LPN) and try again. They stated if a resident was as on weekly weights, they should be done weekly. During an interview with LPN #35 on 3/7/22 at 12:34 PM, they stated the registered nurse (RN) Unit Manager, or the LPN would complete the assignment sheet that would note if a resident required to be weighed by a CNA. CNAs would then obtain the weights and write them in the book. If a resident declined, staff would re-approach. The LPNs then entered weights from the sheet into the computer. Weekly weights were to be done weekly to keep track of weight gain/loss and nutritional status, especially on a floor that had more residents with diagnoses of dementia. They stated they did not know if the resident declined to be weighed but did not think they had. They stated the resident's weights fluctuated recently and the resident had been started on 2 Cal HN because of weight loss. During an interview with RN Unit Manager #21 on 3/7/22 at 12:42 PM, they stated weights, including weekly weights, would be noted on a CNA assignment sheet by them or the LPN. If a re-weight was needed RD #25 would let them know via telephone, verbally or in e-mail. The LPN was responsible for checking that weights were completed and entered into the electronic record. The RN Manager stated they were aware weekly weights had started for the resident in 8/2021. The resident had weight loss and in 11/2021, they had a hard time getting the resident to eat. They stated it was important to monitor weights related to the resident's variable intakes. During an interview with RD #25 on 3/7/22 at 2:31 PM, they stated the resident had crazy weights. The resident's weight had stabilized in 10/2021, and they were not concerned at that time. In 11/2021, the resident had a significant weight loss at 3 months, and it was desired the resident's weight would stabilize. The RD stated it seemed the resident's weight declined in 2/2022. The Levothyroxine could affect weight, and they planned for weekly weight to continue and made the physician assistant (PA) and social services aware. The RD felt the resident had a weight loss in 2/2022 related to a change in medication and a high TSH level. When there was a weight loss, they tried to figure out the root cause of the weight. They would keep the resident on weekly charting related to concern with the resident's weights. The resident continued on weekly weights. They had talked to the NP about keeping weekly weights in place as well. The RD requested 2 Kcal when the resident's weight reached 119 pounds. They did not put a supplement into place prior to this. 10NYCRR 415.12(i)(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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Based on observation, record review and interview during the recertification and abbreviated (NY00281008) surveys conducted 3/1/22-3/8/22, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 staff (registered nurse [RN] Unit Manager #21, receptionist #31, security guard #27, and activity aide #30) observed. Specifically, RN Unit Manager #21, receptionist #31, and security guard #27 were observed wearing masks inappropriately and security guard #27 and activity aide #30 wore masks of unsuitable materials. Findings include: The facility policy Coronavirus (COVID-19) dated 2/22 documents the facility recognizes the need to minimize exposure to respiratory pathogens and promptly identify residents with clinical features and an epidemiologic risk for the COVID-19 and to adhere to Federal and State/Local recommendations. All healthcare personnel will be correctly trained and capable of implementing infection control procedures and adhere to requirements. Health Care personnel must be counseled to continue strict adherence to all recommended non-pharmaceutical interventions, including hand hygiene, and the use of face masks as well as the importance of being vaccinated. The New York State Department of Health (DOH) Health Advisory: Nursing Home Staff and Visitation Requirements dated 1/12/22 documents all staff must be masked at all times, regardless of vaccination or booster status. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic updated 2/22/22 documents source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control options for health care personnel (HCP) include a NIOSH-approved N95 or equivalent or higher level respirator or a well-fitting facemask. During an interview with the Ombudsman Coordinator on 3/1/22 at 1:47 PM, they stated staff did not wear masks, especially the nursing staff on the Terrace Unit. The following observations of staff were made: - on 3/1/22 at 12:15 PM, receptionist #31 was sitting at the reception desk with their mask below their nose. - on 3/1/22 registered nurse (RN) Unit Manager #21 had their mask below their nose at 12:48 PM, within 6 feet of the surveyor. They shifted the mask at 12:51 PM and it remained with their nose exposed; and at 3:37 PM, walking with a resident and standing next to another resident. - on 3/2/22 at 8:39 AM security guard #27 was wearing a black cloth neck/facial guard with the facial guard under their chin with their mouth and nose exposed. Security guard #27 stated everyone in the facility was to wear a mask. The security guard was observed wearing a black cloth neck/facial guard on 3/4/22 at 9:30 AM and 3/7/22 at 8:35 AM, and on 3/8/22 at 8:45 AM and 8:50 AM, with their nostrils exposed. - on 3/4/22 at 9:10 AM, receptionist #31 was behind the reception desk and was not wearing a mask, while 2 unidentified individuals were screening to enter the facility. The receptionist stated everyone was to wear a mask when they entered the facility and they had been educated on mask use. They stated they were responsible for making sure everyone had a mask on. - on 3/4/22 at 12:23 PM, activity aide #30 was observed wearing a leopard patterned cloth mask. The aide was walking through the dining room and assisted one resident with cutting their meal items and then talked with several other residents. During an interview with security guard #27 on 3/8/22 at 8:50 AM, they stated they were responsible for making sure visitors were screened and that everyone entering the building was wearing a mask. The security guard pulled their cloth neck/facial cover below their chin and proceeded to talk with their mouth and nose exposed. During the interview 2 staff came to self-screen and were within 3 feet of the security guard. The security guard stated they were allowed to wear any type of mask if covered their mouth and nose. They stated if someone came in without a mask, they would give them an ear loop mask. Security guard #27 stated they were not vaccinated against COVID-19 or influenza. During an interview with Infection Control RN #7 on 3/8/22 at 1:19 PM, they stated the security guards were required to wear an ear loop mask or an N95. Staff were not to wear cloth masks or respirator masks. If they did, an ear loop mask was required underneath. They stated when wearing a mask, it should be up over the mouth and nose. The Infection Control RN stated they had spoken to the security guard in the past and they should not have been wearing a cloth neck/facial covering. 10NYCRR 415.19

CONCERN (D)

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

Deficiency F0888 (Tag F0888)

Could have caused harm · This affected 1 resident

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Based on observation, record review and interview during the recertification and abbreviated (NY00281008) surveys conducted 3/1/22-3/8/22, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 and include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19 for 3 of 11 staff (security guards #27, 28, and 29) reviewed. Specifically, the facility did not maintain documentation of COVID-19 vaccination status for 3 contract staff, security guards #27, 28, and 29, and did not implement a contingency plan to address non-vaccinated employees. Findings include: The facility policy Coronavirus (COVID-19) dated 2/22 documents health care personnel must be counseled to continue strict adherence to all recommended non-pharmaceutical interventions, including hand hygiene, and the use of face masks as well as the importance of being vaccinated. (All employees are offered and encouraged to get COVID-19 vaccination boosters). No Unvaccinated employees can work here. Resident and staff testing will be done as directed by DOH (Department of Health) and/or if any symptoms are present. The policy did not include a process for tracking and securely documenting the COVID-19 vaccination status of all staff or contingency plans for staff who were not fully vaccinated for COVID-19. Security guard #27 was observed wearing a black cloth neck/facial guard: - On 3/2/22 at 8:39 AM, with the facial guard under their chin with mouth and nose exposed. - On 3/4/22 at 9:30 AM, and - On 3/7/22 at 8:35 AM. There was no documented evidence security guard #27 was tested for COVID-19 when test results were requested from the Administrator on 3/7/22. During an interview with security guard #27 on 3/8/22 at 8:50 AM, they stated they had worked at the facility full time for some time. They stated they were not vaccinated against COVID-19 and got tested about once a month for COVID-19. They stated there were 15-minute rapid tests available to take, but they had not taken any as they had not had any symptoms. They stated they were around residents who were waiting for family or appointments in the lobby. They stated they could wear any material mask if their mouth and nose was covered, and they had not been fit-tested for an N95 mask. On 3/8/22 at 11:13 AM, the Director of Human Resources stated they did not keep COVID-19 vaccination status for their contract staff and the contract company was responsible for ensuring the employees were vaccinated. They stated they did not conduct COVID-19 testing on contract employees and did not have any copies of testing or vaccination status for security guard #27 for 2022. On 3/8/22 at 11:29 AM, the Administrator documented in an e-mail that the security guards were required to have the COVID-19 vaccination to work in health care. The guards' employer was responsible for documentation/compliance. The facility would test the guards if they showed signs of infection. During an interview with Infection Control registered nurse (RN) #7 on 3/8/22 at 1:19 PM, they stated the contract company was responsible for tracking the security guard's vaccinations. They knew at some point the security guard did not want the vaccination. The Infection Control RN stated after discussion with the security guard, they thought the security guard received the COVID-19 vaccination. The Infection Control RN stated the facility did not keep track of the contract company's security guard COVID-19 vaccinations and thought security guards #27, 28 and 29 were vaccinated. They stated they had not asked the company for record of their vaccinations. Infection Control RN #7 stated the facility required all their employees to be vaccinated. Infection Control RN #7 stated if an employee was not vaccinated, they would need to be tested twice weekly. Since they did not know the security guard was not vaccinated, they did not test them. They stated if an employee was not vaccinated or partially vaccinated, they would have been removed from work. During a follow up interview with Infection Control RN #7 on 3/8/22 at 2:40 PM, they stated they did not count the facility's contract employees, including the security guards, in their National Healthcare Safety Network reporting on percentage of vaccinated staff. They stated the remaining contract employees in other areas of the building were all fully vaccinated. During an interview on 3/8/22 at 2:48 PM, the Infection Control RN stated the Director of Facilities was responsible for the security guards and was attempting to contact the contract company to obtain vaccination information as they did not have or retrieve it prior to this date. When they spoke with the company on the phone, they stated security guards #28 and 29 were vaccinated against COVID-19, but they had not yet been supplied documentation. 10NYCRR 415.19(a)(1)

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 nursing units (Terrace Unit, Unit 1, and Unit 2) and for 2 of 2 residents (Residents #10 and 63) reviewed. Specifically, the Terrace Unit had unclean rolling window shades in the dining room and a torn fall mat in resident room [ROOM NUMBER]; Unit 1 had a damaged ceiling in the Ridge shower room and loose handrails; and Unit 2 had a damaged section of wall in resident room [ROOM NUMBER]. Additionally, Resident #10 had an unclean wheelchair and Resident #63 had an unclean scoot chair. Findings include: The facility policy Resident Services - Maintenance of Facility updated 4/1/17, documents a maintenance logbook will be kept in the Maintenance shop for documentation of areas in need of maintenance services and work orders should be called into [specified extension] from any phone in the building. Staff will be responsible to report maintenance needs for repair, cleaning, equipment failure, etc., to the supervisor. Terrace Unit The following observations were made of Resident #63's scoot chair on the Terrace Unit: - on 3/2/22 at 9:45 AM, the foot pedals had a white dried substance on them. - on 3/3/22 at 9:33 AM, the chair arms and foot pedals had a white dried substance on them. - on 3/4/22 at 2:12 PM, the scoot chair had a white dried on substance on it. - on 3/7/22 at 10:58 AM, the foot pedals had a white dried on substance on them. The following observations were made of the Terrace Unit dining room window rolling shades: - on 3/2/22 at 10:45 AM, there were three window rolling shades that had food splatter/stains on them. - on 3/3/22 at 4:58 PM, there were three window rolling shades that had food splatter/stains on them. During an interview on 3/3/22 at 4:58 PM, the Maintenance Director stated they were not aware of the Terrace dining room window rolling shades had food splatter/stains on them. The Director stated they would check and see if any work orders had been made for the shades. During an interview on 3/7/22 at 9:33 AM, the Maintenance Director stated there were no work orders for the Terrace dining room rolling shades having food splatter/stains on them. During an observation on 3/3/22 at 2:15 PM, there was a fall mat in resident room [ROOM NUMBER] with a 36-inch tear in it with exposed foam. Unit 1 During an observation on 3/1/22 at 3:30 PM, a 9-inch x 12-inch section of a solid ceiling in the Ridge shower room was peeling from the ceiling. During an observation on 3/1/22 at 2:00 PM, there was a loose 3-foot section of a wall handrail near the dietitian office. Unit 2 The following observations were made of Resident #10's wheelchair: - on 3/2/22 at 10:58 AM, the entire left side and wheelchair wheels/wheel prongs were unclean/soiled with splattered material. - on 3/4/22 at 4:17 PM, the entire left side and wheelchair wheels/wheel prongs were unclean/soiled with splattered material. - on 3/7/22 at 9:54 AM, the wheelchair wheels/wheel prongs were unclean and soiled. The following observations were made of damaged walls: - on 3/1/22 at 2:20 PM, there was a wall covering under a windowsill in the Unit 2 dining room that was not attached and was taped to the wall. - on 3/2/22 at 9:55 AM and 3/7/22 at 10:10 AM, there was a 1-foot x 1-foot section of wall near the bed in resident room [ROOM NUMBER] that was poorly patched/damaged. During an interview on 3/3/22 at 4:40 PM, the Maintenance Director stated there was no work orders for the findings identified during survey. They stated that staff could call a specific maintenance department phone number and/or send an email to a specific maintenance department email, and the maintenance staff would generate a paper trail/work order. The Maintenance Director stated all staff were aware of this specific phone number and email, and all staff were responsible to properly report identified findings. They stated that they were not aware of any of the observed findings. During an interview on 3/7/22 10:13 AM, the Maintenance Director stated he was not aware of the damaged section of wall in room [ROOM NUMBER], a work order should have been completed and they were unable to locate a work order. They stated wheelchairs were cleaned by the overnight nursing staff, and maintenance and housekeeping departments were not responsible for completing this task. During an observation and concurrent interview on 3/7/22 at 10:58 AM, registered nurse (RN) Unit Manager #21 stated they were not aware of the Terrace Unit dining room rolling shades having food splatter/stains on them. They stated that resident wheelchairs, scoot chairs, and other mobility chairs should be cleaned when residents were having their weekly showers. RN Unit Manager #21 stated that some resident wheelchairs needed to be cleaned more frequently due to resident habits or family bringing in food. The Wheelchair Cleaning Schedule for the third shift was the expected cleaning schedule and depending on the staff availability the actual cleaning of resident wheelchairs may not have been documented. RN Unit Manager #21 stated that outside of visual checking there was no way to ensure the chairs were cleaned. RN Unit Manager #21 observed Resident #63's scoot chair and stated the scoot chair was not clean and would expect nursing staff to contact them if they observed unclean resident chairs. RN Manager #21 stated that nursing staff was responsible for cleaning resident wheelchairs, scoot chairs, and other mobility chairs. They stated that staff should be completing shower sheets and on shower sheets there was a spot to date and time when a chair was cleaned. During an interview on 3/7/22 at 11:15 AM, RN Unit Manager #2 stated they were not aware of damaged ceiling in the Unit 1 Ridge shower room. They stated that nursing staff should either call a specific maintenance department phone number and/or send an email to a specific maintenance department email if there were concerns. RN Manager #2 stated that resident wheelchairs, scoot chairs, and other mobility chairs were cleaned during their shower and as needed and was documented on the shower sheets. During an interview on 3/7/22 at 11:42 AM, Support RN #3 stated resident wheelchairs were cleaned on the resident shower days, was documented on shower sheets, and that the shower timeframe/frequency was located on the resident care plan sheet. Upon observation of Resident #10's wheelchair, the damaged section of wall within resident room [ROOM NUMBER] and the damaged wall covering under a windowsill in the Unit 2 dining room they stated that there were not aware of these areas. RN #3 stated the wheels of a wheelchair were considered part of the chair and should be cleaned at same time as the chair. They stated for maintenance issues they should call the direct maintenance phone number or email the maintenance department. 10NYCRR 415.29(j)(1)

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, record review, and interview during the recertification survey conducted 3/1/22-3/8/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 main kitchen reviewed. Specifically, there were damaged sinks, unclean/soiled floors, unclean soiled deep fryers, unused lids, and containers stored on an unclean shelf, improperly stored food scoops, missing ceiling tiles, and uneven floor surfaces. Findings include: The undated facility weekly 7-3 & 3PM Shifts task sheet and the undated Daily Cleaning Lists did not include: - cleaning the floors within and around the cooking areas; - cleaning cooking equipment and food surfaces; and - to report deficient issues identified as per the facility maintenance policy. The following kitchen observations were made on 3/1/22 between 12:30 PM-1:30 PM: - the kitchen hand wash sink near the meat cooking area was loose and not attached to the wall; - the corner of the floor near the meat cooking area stove had loose grains of rice; - a water pipe connected to the baking/production two bay sink faucet had a leak and sprayed water when turned on; - the scoop for the dairy side flour was inside the flour bag; - both dairy cook area deep fryers were soiled; - the floor around the dairy cook area deep fryers had French fries and miscellaneous debris on it, and directly under the fryers the floor had an unclean black substance; - the dairy area steam table had over 50 multiple sized plastic lids and paper containers lying loosely on the unclean bottom shelf. There was miscellaneous microfiber and plastic lids kept in an unclean detergent container. - the dairy preparation line area of the kitchen had open 2-foot (ft) x 3 ft ceiling tile. - the dish machine room had a missing 8-inch x 3 ft ceiling tile, and a 4-inch x 2 ft missing ceiling tile. The following kitchen observations were made on 3/3/22 at 12:21 PM: - the floor in the produce cooler had an uneven one-inch lip which was a tripping hazard. - the corner of the floor near the meat cooking area stove had loose grains of rice; and - the scoops for the meat cooking area chicken based powder, the vegetable based powder and beef based powder were stored inside of the containers. A scoop for brown rice was inside the brown rice bag. During an interview on 3/3/22 at 12:21 PM, the Food Service Director stated that a work order for the leaking baking/production two bay sink faucet was submitted on 3/3/22. During an interview on 3/3/22 12:44 PM, the Food Service Director stated the black substance on the floor under the dairy cook area deep fryers was grease, and the person that was tasked to clean the kitchen floors was a no call/no show on Sunday 2/27/22. They stated that there was no current cleaning checklist, staff were just reminded of their tasks as needed, and this has been the process since September 2021. The Food Service Director stated that they had to cover the 11 AM to 6 PM shift on 2/27/22 because the kitchen was short staffed. The Director stated they were responsible for cleaning the floors that day. They stated that there was no signoff sheet that would indicate that the daily cleaning of the floors and walls was completed. They stated maintenance staff would clean ceiling tiles as needed. The Food Service Director stated that the rice on the meat cooking area floor did not look like it had just occurred. They stated it was not acceptable to have food on the floor from the night before, and that there should never be any items kept on the lower shelf of the steam tables. The Food Service Director stated that the shelf under the dairy cook area steam table was supposed to be cleaned after each meal, it was not being done, and a kitchen manager should check this daily to ensure this shelf stayed empty. They stated that the dairy cook area was used by staff every day and the items on the shelf were overlooked. They stated they were not sure how long the cup lids and containers were on the shelf, and that this shelf should be wiped clean daily. They stated when a ceiling tile was missing, dust and other particles could fall from the space above the ceiling into the food production area. There were no specific work orders regarding missing ceiling tiles. The Food Service Director stated the missing ceiling tile by the preparation line area was from a leak on 1/22/22. The Food Service Director shared a video of the water leak and an email from maintenance worker #22 documenting the ceiling tile was going to be replaced 1/24/22. The Food Service Director stated that maintenance worker #22 was made aware of the loose handwash sink last week on 2/23/22 or 2/24/22 and thought that it would have been corrected. They stated that scoops should not be kept inside containers when not in use. During an interview on 3/3/22 at 4:40 PM, the Maintenance Director stated that staff could call a specific maintenance department phone number and/or send an email to a specific maintenance department email, and the maintenance staff would generate a paper trail/work order. They stated that all staff had been made aware of this phone number and email and were responsible to properly report identified issues. During an interview on 3/4/22 at 12:17 PM, the Maintenance Director stated there were no work orders for the issues identified during the tour of the kitchen. During an interview on 3/4/22 at 12:38 PM, maintenance worker #22 stated on 1/22/22 the heat unit located on the kitchen roof had burst and water had run down the pipe onto a kitchen ceiling tile. They stated they had forgotten to replace the ceiling tile. 10NYCRR 415.14(h)

Sept 2019 16 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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure each resident had the right to a dignified existence for 1 of 18 residents (Resident #122) reviewed for dining. Specifically, Resident #122 was not served his meal timely after his tablemates had been served. Findings include: The Physical Care/ADLs policy dated 10/3/2014 documented the facility assured each resident received routine physical care designated to keep them clean, comfortable, safe and in good health. All activity of daily living (ADLs) instructions were located on the certified nurse aide (CNA) assignment sheet. The resident dignity policy dated 1/21/2000 documented the facility promoted care for residents in a manner that enhanced each resident's dignity. Resident #122 was admitted to the facility on [DATE] with diagnoses of fractured femur (thigh bone) and dementia. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and required extensive assistance for activities of daily living (ADLs). The 9/10/19 CNA assignment sheet documented the resident required set up at meal time and was independent with eating. The physician order dated 9/5/19 documented the resident received a regular diet On 9/8/19 at 5:40 PM Resident #122 was observed in the dining room awaiting his evening meal. At 5:40 PM the resident's four tablemates were served their meal and received staff assistance. The resident received his meal at 5:58 PM. At that time, 2 of his tablemates had finished eating and left the dining room, the remaining two table mates had been assisted and fed by CNA #6 and were waiting to be taken from the dining room. During an interview on 9/11/19 at 10:54 AM, CNA #1 stated that residents were to be served their meals table by table. One licensed practical nurse (LPN) and one CNA passed the trays. She stated that all residents at a table were served before moving to the next table. She stated 18 minutes was too long for the resident to wait for a meal after the other residents at the same table were served. She stated that it was a matter of dignity and a resident would probably not feel good about waiting so long. During an interview on 9/11/19 at 12:12 PM, LPN #2 stated the meals were passed by one LPN and a CNA. The LPN and CNA expedited the meal service when they passed the trays of food. She stated 18 minutes was too long for a resident to wait for food when other table mates were served. During an interview on 9/11/19 at 12:16 PM, registered nurse (RN) Unit Manager #3 stated a resident should not wait 18 minutes after the other residents at the same table were served. She stated it did not provide a comfortable atmosphere and would be an issue of dignity as well. 10NYCRR 415.5(a)

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

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 the recertification survey, the facility did not ensure that residents were assessed to determine ability to safely self-administer medications, when clinically appropriate, for 1 of 1 resident (Resident #25) reviewed for medication self-administration. Specifically, Resident #25 was observed with a medicated cream in her room and there was not a physician order or interdisciplinary team (IDT) determination the resident was clinically appropriate to self-administer medications. Findings include: The 6/2017 Self Administration of Medications by Resident Policy documents that the physician or nurse practitioner (NP) will determine if it is safe for the resident to self-administer medications before the resident may exercise that right. Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and age-related osteoporosis (bone loss). The 6/14/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was independent for most activities of daily living, required limited assistance with dressing, and had moderate constant pain. The 10/31/16 comprehensive care plan (CCP) documented the resident was at risk for pain. The 4/5/18 updated CCP documented the resident had cognitive deficits, had impaired long-term and short-term memory, limited judgement and safety awareness due to dementia. There was no documentation the resident could self-administer medications. The 6/23/19 physician order documented the resident received BenGay (pain reliever) topical ointment every 4 hours to both shoulders and it was to be alternated with Lidocaine (local anesthetic) ointment. There was no documentation the resident could self-administer medications. The 9/2019 Treatment Administration Record (TAR) documented licensed practical nurses (LPNs) provided the resident with BenGay three times a day at 4:00 AM, 12:00 PM, and 8:00 PM; the resident refused the 4:00 AM administration on 9/4/19 and 9/10/19, and all other administration times were signed for by the LPN. LPN #7 administered BenGay on 9/9-9/11/19 at 12:00 PM. On 9/9/19 at 9:51 AM, the resident was observed in her room in her recliner chair with BenGay on her bedside table. The resident stated it was usually left in her room, she put it on herself, and she applied it to her shoulder and her hip. On 9/11/19 at 8:19 AM, the resident was observed at the breakfast table. The surveyor went into her room which had a strong menthol odor like that of BenGay. The 9/11/19 TAR from 9:00 AM documented the resident refused her BenGay topical patch application that morning, and the last BenGay cream application was at 4:00 AM. The resident's drawer was locked. During an interview on 9/11/19 at 9:18 AM, licensed practical nurse (LPN) #7 stated residents would have an order if they could self-administer medications. She stated she did not know if the resident could keep the BenGay at her bedside and the LPN would put the cream on the resident. During an interview on 9/11/19 at 10:12 AM, acting registered nurse (RN) Unit Manager/RN Staff Educator #8 stated if a resident could self-administer medications, there would be an order and it would be in the CCP. She reviewed the resident's chart, and the resident did not have an order to self-administer and it was not in the care plan. 10NYCRR 415.3(e)(1)(vi)

CONCERN (D)

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

Deficiency F0568 (Tag F0568)

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 the facility did not ensure the individual financial record was available to the resident through quarterly statements and upon request for 1 of 1 resident (Resident #14) reviewed for personal funds. Specifically, Resident #14 did not receive quarterly personal account statements from the facility as requested. Findings include: The 6/2007 Personal Incidental Allowance policy documented the finance department will make available to all residents a personal incidental allowance trust account for the purpose of holding monies to enable the resident to have funds available for incidental expenses. Residents are entitled to manage their own financial affairs if they choose. When a resident's personal account is established, it will be entered into the computer which will track each withdrawal and the balance at each transaction. A copy of this ledger may be obtained by the resident at any time by request; however, a balance will be provided to the resident or the resident's legal representative on a quarterly basis. Resident #14 was admitted to the facility on [DATE] and had a diagnosis including depression. The 2/14/19 and 6/6/19 Minimum Data Set (MDS) assessments documented the resident was cognitively intact. The comprehensive care plan (CCP), updated 1/9/19, documented the resident needed adjustment to long term care and had impaired memory. Interventions included be available to respond to the resident's concerns at her request, respect her rights, and anticipate and meet unexpressed needs. The 5/31/19 psychiatric consult documented the resident was married, and her spouse hardly ever visited. The consult documented her thought processes were logical, goal oriented, she was oriented and her long-term memory appeared to be adequate. The resident's quarterly personal funds account statements reviewed between 4/2018-9/2019 documented as addressed to her home mailing address, and not the facility where she had resided since 4/2018. When interviewed on 9/8/19 at 4:59 PM, the resident stated her account statements went to her spouse, he was no longer involved in her care, and he did not come to the facility. When interviewed by telephone on 9/10/19 at 1:12 PM, the resident's spouse stated he received account statements from the facility on a routine basis. He did not answer if he shared the information with the resident when asked by the surveyor. When interviewed on 9/10/19 at 1:15 PM, receptionist #23 stated personal fund account statements were sent quarterly and some were sent every month if the resident requested. The statements would go to the financially responsible party and she did not think any resident in the facility received one. If a resident was cognitively intact, the facility could send a statement, but she did not remember encountering such a scenario. When interviewed on 9/10/19 at 1:21 PM, comptroller #24 stated policy documented the facility sent resident account statements quarterly, if in the red, or if the account went below 25 dollars. Policy dictated the statements go to those financially responsible per the resident's admission agreement, which meant whomever was responsible for paying the resident's bills. She stated the facility did not have any resident in the facility who was responsible for their own account. She stated any resident could ask at any time how much was in their account and they would be shown the balance. She stated the facility did not keep records when statements were mailed out to either the resident or their family. When interviewed on 9/10/19 at 2:11 PM, the Administrator stated each cognizant resident received a quarterly account statement and Resident #14's was sent to her home address which was the address on her statement. He stated the account statement was sent to the home address if a resident was cognitively intact, unless they instruct the facility otherwise. The resident could then get it from their families or when they returned home if they were admitted for short term rehabilitation. He stated that had been the billing office's procedure for a long time. During a second interview on 9/11/19 at 9:37 AM, Resident #14 stated she started in short term rehabilitation and was now at the facility for long term care. She stated her spouse lived at home and she had not talked to him in approximately 6 months. She stated she had an account if she wanted to go to the gift shop. The facility told the resident they sent bills and statements to her spouse. She stated she did not know how much was in the account as he did not tell her, and she had never received an account statement from the facility. She stated she did not know she could receive account statements or ask about them. When interviewed on 9/11/19 at 11:12 AM, licensed practical nurse (LPN) #25 stated the resident's spouse had not been to the facility or had contact with the resident in a long time. When interviewed on 9/11/19 at 11:42 AM, certified nurse aide (CNA) #26 stated the resident could not return home, the resident's spouse no longer visited or communicated with her, and she had not heard the resident speak to the spouse over the phone. When interviewed on 9/11/19 at 12:14 PM, registered nurse (RN) Unit Manager #27 stated the resident was cognitively intact and could make her own decisions. She was aware the resident's spouse had not seen her for over 6 months. When re-interviewed on 9/11/19 at 4:24 PM, comptroller #24 stated statements were sent to the resident's home address or the address in computer, and the family was responsible to update the resident as to their account summary. If the family did not bring the statements in or talk to the resident about the account, the resident could come to the receptionist and inquire. If they were not aware, they could inquire and if family did not update them, then she was not sure how the resident would be aware of how to obtain statements. 10NYCRR 415.26(h)(5)(iii)

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 record review and interview during the recertification survey, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 3 of 5 residents (Residents #25, 99 and 322) reviewed for accidents. Specifically, Resident #25 had a fall and staff statements were not completed to determine if the care plan was followed. Residents #99 and 322 had falls and investigations were not thorough to rule out abuse, neglect or mistreatment. Findings include: The 4/2019 Resident/Abuse/Neglect/Exploitation Policy documented the residents have the right to be free from verbal, physical and mental abuse, mistreatment and neglect. Residents have the right to have their care plans followed at all times. All reports of Abuse/Neglect will be investigated, regardless of who reports them. 1) Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and age-related osteoporosis (bone loss). The 6/14/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was independent for most activities of daily living, and had no falls. The 10/18/16 comprehensive care plan (CCP) documented potential for falls with history of falls with a goal to limit and prevent falls. Interventions included answer call bell promptly; call bell within reach; shoes and or non-skid socks at all times when out of bed; floor uncluttered; bed in lowest position; check assistive devices daily for damage; check all locks are working on wheels to bed, commode, wheelchairs; adequate lighting; personal items within reach; bed against wall; non-skid strips on floor; personal alarm on at all times; wheelchair with anti-tippers; may kneel on floor; do not leave unattended in bathroom; and seat alarm in wheelchair. The 9/5/19 update to the CCP documented the resident had a fall on 9/2/19 with bruising. The 9/3/19 registered nurse supervisor (RNS) #18 progress note documented the resident had a 10-centimeter (cm) x 10 cm bruise to her left shoulder, the resident stated she did not know how it happened, and the resident denied pain. There was no previous documentation that the resident had a fall or monitoring after the fall. The 9/5/19 RNS #15 progress note documented a late entry for 9/3/19 at 7:10 AM, the certified nurse aide (CNA) reported she found the resident in front of her recliner on the floor, and the resident stated she slid from her chair. The 9/5/19 at 10:33 AM acting RN Unit Manager #8 progress note documented the resident had a fall on 9/3/19 during the day shift with various bruising noted to her bilateral upper extremities, bilateral lower extremities, and left cheek. The 9/5/19 at 12:18 AM acting RN Unit Manager #8 documented the RN spoke with the resident's daughter, who requested a personal alarm at bedtime. During an interview with the resident on 9/9/19 at 10:01 AM, she stated she was told she had a fall last week, she did not know what happened, and she bruised her face, shoulders, and back. She thought she slid off her chair but she said it couldn't be from that, she didn't remember falling, and the staff asked her the next day how she fell. On 9/9/19, the 9/2019 Accident and Incident Reports for Resident #25 were requested from the facility. The resident had an incident report that did not include the date and time of the incident or who completed the report. The incident description was resident sitting on floor in front of recliner, no injury was checked then crossed through. The resident had bruising to her bilateral upper extremities, bilateral lower extremities, and her left cheek (the diagram depicting body areas was not completed). The resident's daughter and physician were notified on 9/2/19 and the time was not noted. The summary of witness statements was blank. The care plan was reviewed on 9/2/19 and was followed. The investigator signature by the RN Unit Manager was not dated, the Director of Nursing (DON) signed the investigation on 9/3/19, and the social worker and administrator signature was not dated. There was no documented evidence staff witness statements were obtained to determine the resident's plan of care had been followed at the time of the incident. During an interview on 9/11/19 at 9:18 AM, licensed practical nurse (LPN) #7 stated if she saw a new bruise or a CNA reported a bruise to her, she would notify the RNS or RN Unit Manager, and an investigation would be started, and witness statements would be obtained. If a resident had an unwitnessed fall, everyone working on the shift had to write a witness statement and usually the resident would be on neurology checks. She stated the resident had bruising that developed on her the left side of her face, shoulder, hip, and buttocks; it was reported once it was seen; and no one knew of a fall for her. The resident would deny a fall because she was paranoid about moving to another facility and losing her independence. During an interview on 9/11/19 at 9:33 AM, CNA #26 stated that if a resident had a new bruise or an unwitnessed fall, she would report it to the nurse and an incident report would be started. She stated she would be asked to do a statement for bruising and unwitnessed falls. During an interview on 9/11/19 at 10:12 AM, RN Unit Manager #8 stated she kept track of incident reports, she updated the care plans in morning meetings, and the team reviewed investigations to make sure they were complete. If she was present at the time of the incident, she or the RNS would initiate the incident report and she helped to gather witness statements. She stated last week the resident was found sitting on the floor next to her chair in her room and bruising started to appear after the fall. When showed the Incident Report for the resident, she noted that the header was not filled out with the date, time, and person completing the report. The date next to the notification of the physician and family was 9/2/19 and the nursing progress notes documented the fall was on 9/3/19. She stated they were a little delayed in the documentation, the RNS for the evening shift had started an incident report for the bruising, and that incident report was with the Assistant Director of Nursing (ADON). She stated the bruising was not a separate incident since it could be traced back to the fall. She stated the Incident Report had no witness statements. She stated incident reports always had witness statements. An investigation was not complete until there were witness statements and the team would not sign off that the investigation was completed without witness statements. During a follow up interview on 9/11/19 at 12:12 PM, RN Unit Manager #8 stated the resident fell on 9/3/19 and the date on the incident report was incorrect. During an interview on 9/11/19 at 12:44 PM, the DON stated witness statements did not need to include a location since that could be figured out from the time of the incident. Witness statements were obtained for all investigations. They would collect statements from all the staff present on the day of an incident. Often staff did not know about the incident, but they had to write something. She reviewed the resident's incident report and stated there were no witness statements included. During a follow up interview on 9/11/19 at 3:08 PM, the DON stated they do not obtain statements from residents during investigations for unwitnessed falls. 2) Resident #99 was admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, and repeated falls. The Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, had 2 falls with no injury, 1 fall with injury, and required limited to extensive assistance with most activities of daily living (ADLs). The comprehensive care plan (CCP), updated 5/23/19, documented the resident had an ADL self-care deficit and had a history of falls. Staff were to ensure call bell was within reach; answer call bell timely; ensure shoes or non-skid socks were on at all times; ensure non-skid strips were on the floor next to the bed; personal alarm was on at all times; and ensure the wheelchair had anti-rollback and anti-tippers. The 7/14/19 at 5:15 PM Accident/Incident report documented the resident was found on the floor after an alarm was sounding. It was an isolated incident and they would monitor the resident. There was no documentation where the resident was found to ensure the care plan was followed and to prevent further falls. The investigation did not rule out abuse, neglect or mistreatment. The 7/28/19 at 2:00 PM Accident/Incident report documented the resident was found on the floor in the bathroom. The plan was to not have the resident left unattended in the bathroom. The investigation did not document how it was concluded the resident was left alone in the bathroom. It did not rule out abuse, neglect or mistreatment when the investigation did not note if the care plan had been followed to prevent falls and ensure resident safety. The 7/28/19 at 6:55 PM Accident/Incident report documented the resident was found on the floor in her room and sustained a skin tear to the right knee. The note documented they would implement non-skid socks. It was noted that certified nurse aide (CNA) #20 was assigned to the resident. The investigation did not rule out abuse, neglect or mistreatment when CNA #20 was not interviewed to determine if the care plan was followed. The documented statements noted the resident was wheeling around and there was no additional documentation of the resident's location to ensure the resident's whereabouts were being monitored. Per the 5/23/19 CCP, the intervention for shoes or non-skid socks had been in place prior to the 7/28/19 fall. The 8/16/19 (no time documented) Accident/Incident report documented an alarm was sounding and the resident was found by licensed practical nurse (LPN) #17 on the floor in the bathroom of another resident's room. The resident had a laceration above the eyebrow. The facility implemented a seat alarm as a result of the fall. The investigation documented the resident's assigned CNA was off the unit at the time of the incident. The investigation did not document when the CNA last saw or provided care to the resident and did not document if it was determined the resident had alternative safety monitoring in place when the CNA was leaving the unit. An 8/16/19 at 4:47 PM nursing progress note documented the resident was sent to the hospital for the fall with a laceration to the right eyebrow. The resident returned to the facility on 8/17/19 at 1:30 PM with stitches. During an interview with CNA #19 on 9/11/19 at 8:37 AM, she stated she did not recall the resident falling on 7/14/19. The resident often got up out of her wheelchair when she was not supposed to stand without staff assistance. The resident had safety alarms in place, but the resident knew how to remove the safety alarms. The resident had dementia and wheeled around all areas of the unit and would self-transfer in many locations. She stated statements should document where a resident was found. During an interview with RN Supervisor (RNS) #15 on 9/11/19 at 9:10 AM, she stated the resident was sent to the hospital in 8/2019 related to a laceration to her head. The resident frequently tried to get up and walk and had several interventions in place to prevent falls. The resident would be adamant about getting up and then would fall. The resident was able to remove safety alarms. She stated she did not know how the staff could monitor the resident more frequently/all the time as the staff had to go in to other resident rooms to provide care. If staff left for a break, they reported off to the charge nurse so that the other CNAs would know they were not in the quad. The RN did not know if an investigation would note if it was determined the CNA reported off as required when off the quad. During an interview with LPN #17 on 9/11/19 at 9:23 AM, she stated that she had been working when the resident had fallen but she could not state the specific dates. The resident would stand up and down from her chair and she had safety alarms in place, but she was able to remove the clip alarm on her own. The resident wheeled all over the unit and staff had to keep an eye on her. She stated either a LPN or RN Supervisor could initiate an incident report. Normally the LPN would get the paperwork out while the RN was completing an assessment and the RN would then ensure completion of the report. Staff were to take breaks at opposite times and should let another CNA know if they were leaving the unit. If the resident's assigned CNA was leaving the unit the resident should be brought in to a more populated area to be monitored. During an interview with RNS #18 on 9/11/19 at 11:41 AM she stated either a LPN or RN could initiate an incident report. She stated sometimes by the time she arrived at the floor the LPN started the paper work, but the RN should finish the incident report before the end of the shift. The report should include statements and assignment sheets. She stated most falls were not witnessed and staff may have heard an alarm going off, so they responded. The incident report should include the location of where the resident was found. The resident would stand up without staff assistance and would be in different areas of the unit. During an interview on 9/11/19 at 12:44 PM, the DON stated witness statements did not need to include a location since that could be figured out from the time of the incident. She stated a lot of times you can put the puzzle together without knowing all the information. They collect statements from all the staff on that day and a lot of times the staff did not know about the incident, but they had to write something. She stated that every report was different, and every situation was different. She said the resident had several falls and she could not remember them all. 3) Resident #322 was admitted on [DATE] with diagnoses of cerebral infarction (stroke), epilepsy (seizures) and dementia. The 4/5/19 baseline care plan documented the resident was non-ambulatory and used a gait belt and rolling walker for transfers with assistance of two staff. The 9/4/19 Fall Risk Tool documented the resident was not at risk for falls. The 9/5/19 nurse practitioner (NP) progress note documented the resident was admitted for short-term rehab after a stroke, had left sided weakness, answered questions somewhat appropriately, and a review of systems was unable to be completed due to dementia. The 9/6/19 certified nurse aide (CNA) assignment sheet documented the resident was to have her bed against the wall, non-skid strips on the bathroom floor and a seat alarm in her wheelchair. She required transfer assistance of 2 with a rolling walker and gait belt, was non-ambulatory, and required assistance of 2 with bed mobility. The resident was to be toileted every 2 hours and as needed and turned and positioned every 2-4 hours and as needed. The 9/8/19 Accidents and Incidents Report documented the resident was found on the floor at 9:30 AM. The resident was last seen at AM med by LPN #25. The resident had swelling to her left wrist and reddened areas to her left arm, she denied pain and performed passive range of motion with no complaints. The undated employee statements documented CNA #33 heard an alarm and went in the resident's room and found her on the floor. LPN #25 had last seen the resident in bed and had given the resident her medications. There was no documented time when the LPN had given the resident medication. Four staff documented they were not there or had not seen the resident. The final summary concluded the care plan was followed and the investigation did not support abuse, neglect, mistreatment, or misappropriation. There was no documentation of the position or location of the resident on floor when she was found, when the resident had last been provided care, if all care planned fall prevention measures were in place when the resident was found on the floor and if the resident had been interviewed on details of the incident. The investigation did not document how it was determined the plan of care was followed and how abuse, neglect, mistreatment, or misappropriation was ruled out. The 9/8/19 at 4:30 PM registered nurse supervisor (RNS) #18 progress note documented the resident had an unwitnessed fall in her room at 9:30 AM. She was found on the floor with bruising to her upper arm and swelling to left wrist. The immediate intervention was an RN assessment and tender mattress. The physician and resident's daughter were notified. The 9/8/19 at 4:31 PM RNS #18 progress note documented the resident had additional swelling of her wrist and stated it hurt. The daughter was at the bedside and the resident was sent to the hospital for an evaluation. The 9/8/19 at 9:46 PM registered nurse (RN) Unit Manager #8 progress note documented the resident was diagnosed with a left wrist fracture and the daughter was aware. During an interview on 9/11/19 at 12:44 PM, the Director of Nursing (DON) stated the resident fell and broke her wrist, the care plan was followed, and a mattress was added to the care plan afterwards. She stated the RNS was responsible for the investigation and ensuring the care plan was followed, and if the box on the form was checked, then it meant the care plan was followed. During a follow up interview on 9/11/19 at 3:08 PM, the DON stated that they interviewed everyone on the unit from that shift, the resident was found on the floor and the resident stated she fell. She reviewed the incident report, she stated that they never got statements from the resident, and none of the witness statements said that the resident stated she fell. She stated CNA #33 heard the alarm and went in the room, if she had seen someone else in the area the CNA would have written it on the statement. She stated the staff was trained on abuse and neglect. When asked why the resident was getting up, The DON stated she thought the resident had been attempting to get up to go to the bathroom, but it was not documented in the report. 10NYCRR 415.4(b)

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 observation, interview, and record review during the recertification survey, the facility did not ensure each resident had a person-centered comprehensive care plan developed and implemented to address the resident's mental and psychosocial needs for 2 of 6 residents (Residents #25 and 107) reviewed for behaviors. Specifically, Residents #107 and 25 did not have person-centered care plans to address their behaviors. Findings include: 1) Resident #25 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. The [DATE] Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was independent for most activities of daily living, had minimal depression symptoms, did not have signs of delirium, and did not exhibit behaviors. The [DATE] comprehensive care plan (CCP) for Mood State documented the resident had altered mood state due to diagnoses of dementia, anxiety, depression, paranoid personality disorder, and visual hallucinations. Interventions included encourage verbalization of feelings, encourage decision making, support self-esteem through positive feedback, encourage participation in leisure and self-care activities, encourage family involvement and visits, and administer medications as prescribed. The CCP updates for [DATE], [DATE], [DATE], [DATE], and [DATE] documented goals met and ongoing. The [DATE] CCP for Behavior Symptoms documented the resident had the potential to exhibit inappropriate behavioral problem as evidenced by paranoid ideation, diagnosis of dementia, visual hallucinations, and episodes of tearfulness. Interventions included, document in the progress notes the intensity, duration or frequency of behavior, notify the physician or nurse practitioner (NP) immediately for changes in behavior, encourage participation in activities of daily living, social service evaluation and follow up, refer to a psychiatrist for further consultation related to behavior, administer medications as ordered by physician, provide redirection or distraction to minimize frequency or duration of behavior, provide reassurance as needed, and when resident is agitated and/or combative, leave them safe and re-approach later when calm; continue to monitor safety. The CCP updates for [DATE], [DATE], [DATE], and [DATE] documented goals met and ongoing. The certified nurse aide (CNA) assignment sheet did not include person centered interventions in place when the resident exhibited behavioral symptoms. The [DATE] social work progress note documented the resident was having paranoid thoughts, she enjoyed 1:1 visits, and enjoyed time alone. The [DATE] social work progress note documented the resident missed her grandsons, the social worker visited her often due to her sadness, and additional emotional support services were set up through the family services program. The [DATE] nursing progress note documented the resident had confusion, sadness, and paranoid thoughts. She said she was waiting for her husband (who was deceased ) to come in and go to bed, she thought people were talking about her, and she felt like a burden. She also did not want to eat anymore. The NP was notified. The [DATE] behavior progress note by nursing documented the resident had increased anxiety, was paranoid about personal property being stolen if she left her room, she refused to go to the dining room and had poor intake at her meal. There was no documentation of interventions provided. During an interview with licensed practical nurse (LPN) #7 on [DATE] at 9:18 AM, she stated resident specific interventions were done by knowing the residents. The resident had some paranoia where she thought people were talking about her and hallucinated at times. She was easily talked down, redirected, and reassured. During an interview with CNA #26 on [DATE] at 9:33 AM, she stated she cared for the same residents every day, she found out what they liked, and used that for redirection. She said sometimes behavior interventions were documented on the CNA assignment sheets. The resident cried and got paranoid at times and talking with the resident sometimes worked and sometimes leaving the resident alone worked. During an interview with registered nurse (RN) Unit Manager #9 on [DATE] at 10:12 AM, she stated she updated care plans quarterly or if there was a significant change. Behaviors and interventions differed from person to person. She would write a general behavioral care plan if a resident had dementia. She would keep the care plan broad and would individualize it later. She did not put behavior interventions on the CNA assignment sheets. The resident would get weepy, and she was easy to talk to. She stated the care plan intervention to provide reassurance as needed was enough for the resident. During an interview with social worker #34 on [DATE] at 11:07 AM, she stated the resident had periods when she would hallucinate. The resident's family did not see the resident as often as the resident would like which was upsetting to the resident. During an interview with the Director of Nursing (DON) on [DATE] at 2:42 PM, she stated that she expected the care plans to be resident specific and RN Unit Manager #9 had been responsible for all the care plans. 2) Resident #107 was admitted to the facility on [DATE], re-admitted [DATE], and had diagnoses including depression, psychotic disorder with delusions, and dementia with behaviors. The [DATE] Minimum Data Set (MDS) assessment documented the resident was cognitively intact, felt depressed, rejected care at times, her behaviors worsened, and required extensive assistance with most activities of daily living (ADLs). The MDS documented the resident felt it was important to have reading materials, snacks between meals, listening to music, being around animals, keeping up with news, going outside in good weather, and participating in religious activities. The MDS documented the resident received an anti-depressant daily. The [DATE] at 10:32 PM nursing behavioral note documented the resident was verbally and physically abusive. Interventions checked were provide a calm environment, check for unmet needs, positive redirection, she refused a snack, and the registered nurse (RN) was notified. The [DATE] at 3:28 PM and [DATE] at 3:24 PM behavioral progress note documented the resident had increased agitation, hit and kicked objects, was crying and had increased anxiety. Interventions checked included provide calm environment, check for unmet needs, she refused snacks, redirect, positive direction, and RN and family were notified. The [DATE] physician progress note documented the resident had episodic bouts of severe behavior disturbances which were well documented by nursing, she was on medications and they were to get the psychiatrist's opinion. The [DATE] psychiatric note documented the resident was just discharged from the psychiatric unit at the hospital as she was uncontrollable at the nursing home, was non-directable, and serious safety concerns were raised about her safety in the environment. She was started on sertraline (anti-depressant) 25 milligrams (mg) daily, Abilify (anti-psychotic) 2 mg daily, and Trazadone (anti-depressant) 50 mg at bedtime. The note documented staff kept the resident's wheelchair away from her bed to prevent her from trying to get out of bed on her own and falling, her long-term memory was good, there were a lot of pictures on her walls and ornaments her daughter had made, and she had an involved family. Staff reported she had been in a better mood since returning from the hospital. The revised [DATE] comprehensive care plan (CCP) documented the resident had behaviors (physical abuse and socially inappropriate) and had adjustment difficulty with long term care. Interventions included monitor for depression and mood changes, notify social services if needed, validate feelings, 1:1 visits, reduce environmental stimuli, provide emotional support, document behaviors, social work evaluation and follow-up, redirect, psychiatric consults, escort to private area if needed, notify physician, orient, re approach, remove from situation, and medications as ordered. The [DATE] MDS assessment documented the resident was readmitted from the hospital on [DATE], felt depressed, received an anti-psychotic and antidepressant daily, and had no behaviors during the assessment period. The [DATE] updated resident nursing instructions documented the resident had behaviors of being physically abusive, resisting care, and kicking/hitting. The instructions did not document interventions. The [DATE] through [DATE] certified nurse aide (CNA) documentation did not document any behaviors. During an interview on [DATE] at 11:12 AM, licensed practical nurse (LPN) #25 stated CNAs knew how to provide resident specific care via care instructions. She stated behaviors were documented in the template by only using check boxes. She stated the resident threw things in her room, tied the call bell around her arm, yelled and spit at staff in the past. The bed remote was secured to the arm rest of bed. She stated the CCP was completed by the unit manager and LPNs were not able to change or modify them. She stated she provided input to the care plan when she was asked by the Unit Manager and they addressed issues with medical. She stated behavioral interventions included medications, talking about the weather and family, and explained those interventions were used with every resident. During an interview on [DATE] at 11:42 AM, CNA #26 stated the resident's behaviors included fabricating stories about how staff treated her. She stated the resident became physical and tried to hit and spit at staff. She stated the resident would swear and threw objects in her room. She stated the CNAs notified the nurse about behaviors and tried use redirection by talking to her about her family to calm her. She stated the supervisor was called if redirection did not work. During an interview on [DATE] at 12:14 PM, registered nurse (RN) Unit Manager #27 stated CNAs know resident specific care via resident specific care plans. The RN Unit Manager was responsible for initiating and updating the CCP. The LPNs were responsible for informing the RN of any issues and the RN wrote a progress note. The resident had behaviors of yelling, kicking, being verbally abusive to staff and, threatening to throw herself out of bed. Behaviors interventions included redirection, offer snacks, toileting, quiet atmosphere, nurse practitioner (NP) assessment if necessary, psychiatry as needed, the facility's consultant mental health services provide counseling and friendly visits, and try to determine the root cause of the behaviors. She stated behavior CCPs were updated by the RN Manager or social worker. She stated the resident did not have any resident specific interventions. During an interview on [DATE] at 1:01 PM, RN #8 stated prior to the last month, she did all resident CCPs and currently the Unit Managers were responsible to complete them. She stated it was expected that the CCP was resident specific. She stated templates were used initially and then specifics were added to each CCP. CNAs were instructed that resident interventions were to keep the resident safe, leave them to calm down and then re-approach, and they were not resident specific. She stated the resident's CCP did not have resident specific interventions. During an Interview on [DATE] at 2:40 PM, the Director of Nursing (DON) stated she expected the CCP to be resident specific and multiple interventions would be tried for the resident's behaviors. 10NYCRR 415.11(c)(1)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey the facility did not ensure that each resident and/or resident representative, was involved in developing the plan of care and making decisions about his or her care for 1 of 2 residents (Resident #14) reviewed for care plans. Specifically, there was no documentation that Resident #14 was invited to attend her comprehensive care plan meeting. Findings include: The undated Interdisciplinary Care Plan Meeting policy documents social services is responsible for coordinating the meeting, residents are invited to significant change and annual meetings, social services invite residents and their responsible parties to the meeting, and a sign in sheet will be placed in the care plan section of the chart. Resident #14 was admitted to the facility on [DATE], re-admitted on [DATE], and had a diagnosis including major depressive disorder. The 2/14/19 Minimum Data Set (MDS) significant change in status comprehensive assessment documented the resident was cognitively intact, had a change in behavioral symptoms, and required extensive assistance with most activities of daily living (ADLs). The resident's comprehensive care plan meeting sign-in sheets between 2/1/19 and 9/11/19, had no documentation the resident was invited/attended/declined invitations to the comprehensive care plan meetings. The 5/2019 CCP documented the resident had multiple comorbidities including visual and hearing deficits, assistance from staff with ADLs, acute changes in mood/behaviors, history of falls and pain, risk for weight loss and skin breakdown/impairment, and alteration in sleep patterns. Staff were to keep the resident and family informed through team meetings and 1:1 updates. During an interview with the resident on 9/8/19 at 4:57 PM, she stated that she was not invited to care plan meetings. During an interview with the Director of Social Services on 9/11/19 at 10:50 AM, she stated residents were invited to their annual and significant change comprehensive assessments. She stated the resident should have been invited to her significant change care plan in 2/2019, it may not have happened, and she could not remember if she was invited. If there was not documentation, she could not say if the resident was invited or attended. 10NYCRR 415.11(c)(2)(ii)

CONCERN (D)

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 observation, record review and interview during the recertification survey the facility did not ensure all residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1of 8 residents (Resident #52) reviewed for ADLs. Specifically, Resident #52 was not provided personal hygiene and toileting timely. Findings include: The Physical Care/ADLs policy dated 10/3/14 documented the facility assured each resident received routine physical care designated to keep them clean, comfortable, safe, and in good health. The policy documented all activities of daily living (ADLs) instructions were on the certified nurse aid (CNA) assignment sheet. Resident #52 was admitted to the facility on [DATE] with diagnoses including dementia, weakness and depression. The 7/3/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance for toileting and hygiene and was frequently incontinent of bowel. The comprehensive care plan (CCP), dated 6/10/19, documented the resident had deficits related to ADLs and required assistance for bathing, dressing, toileting and grooming and was at risk for skin breakdown related to bowel and bladder incontinence. The 9/10/19 certified nurse aide (CNA) assignment sheet documented the resident was to be toileted or changed every 2-4 hours and as needed. On 9/8/19 at 5:00 PM, Resident #52 was observed sitting in her wheelchair in the common area. The area surrounding the resident smelled strongly of bowel movement. The resident was removed from the common area and taken to the dining room by CNA #6. The resident was observed in the dining area from 5:10 PM until 6:46 PM seated at a table with 4 tablemates and the area surrounding the resident continued to smell of bowel movement throughout the meal. During an interview on 9/11/19 at 10:54 AM, CNA #1 stated she would look at the care plan to find out what assistance the resident needed. She stated that she toileted residents before meals and after meals as needed. She stated if she could smell bowel movement in the area of a resident, she would locate the CNA assigned to that resident or would toilet the resident before she brought them to the dining room. She stated a resident that had been incontinent of bowel and not changed was probably uncomfortable and would be at risk for skin breakdown. During an interview on 9/11/19 at 12:12 PM, licensed practical nurse (LPN) #2 stated if a resident was incontinent of bowel in the dining room, she expected they would be removed from the dining area, changed, toileted and brought back to the dining room. She stated the resident would not have been comfortable during the meal and it may affect the people around the resident as well. She stated if the resident remained in a soiled brief it could cause skin breakdown and would be undignified for the resident. During an interview on 9/11/19 at 12:16 PM, registered nurse (RN) #3 stated dining a resident in a soiled brief was never acceptable. She stated it was a matter of dignity and created a poor dining experience for the resident and those around the resident. She stated she expected the resident would have been changed before going to the table to eat. She stated if the resident was not changed after bowel incontinence it could result in a skin issue, it was a dignity concern and an embarrassment for the resident. 10NYCRR415.12(a)(3)

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

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 the recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities for 2 of 3 residents (Residents #22 and 107) reviewed for vision and hearing. Specifically, Resident #22 was not provided his bilateral hearing aids as care planned. Resident #107 requested hearing aids; an audiology consult was ordered and an appointment was not initiated by the facility. Findings include: The 3/2017 Outpatient Consultations policy documented it was the policy of the facility to assure appropriate medical history and pertinent medical and nursing observation are communicated to an outpatient consultant. The policy did not address specific outside consultants or arranging of medical appointments. The 4/2019 certified nurse aide (CNA) Assignment sheets policy documented hearing aids may be collected and kept in the medication carts. All pertinent information may be placed on CNA assignment sheets for staff to use as a guidance tool and it is a reflection of the resident plan of care. 1) Resident #22 was admitted to the facility on [DATE] and had a diagnosis of hearing loss. The 6/13/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not have difficulty hearing, did not wear a hearing aid and was totally dependent on staff for most activities of daily living (ADLs). The comprehensive care plan (CCP) effective 11/12/18 documented the resident was hearing impaired, wore bilateral hearing aids, and required assistance with all aspects of care. Staff were to provide the resident with hearing aids and assist with keeping the hearing aids clean and functional. Physician orders, active in 9/2019, documented nursing staff were to collect the resident's bilateral hearing aids every night and lock them in the medication cart and return to the resident every morning. The 9/2019 medication administration record (MAR) documented the resident was to have his bilateral hearing aids applied at 8:00 AM every morning and removed at 8:00 PM every evening. The 9/2019 certified nurse aide (CNA) instructions documented the resident had bilateral hearing aids that would be placed and removed by nursing. On 9/8/19 at 6:49 PM, the resident was observed in his wheelchair in his room after returning from dinner. The resident did not have hearing aids in. His wife stated that sometimes the nurse forgot to put them in, and they had not been in at all during the day. On 9/11/19 at 8:19 AM, the resident was observed in his wheelchair in the dining room without hearing aids. The September 2019 MAR documented the resident had hearing aids placed at 8:00 AM on 9/8 and 9/11/19. During an interview with licensed practical nurse (LPN) #7 on 9/11/19 at 10:06 AM, she stated the medication administration record (MAR) would notify nursing the resident needed his hearing aids placed each morning. She stated it depended on when she was completing her medication pass as to when the resident would receive his hearing aids. The resident did not have them placed at a consistent time each day. She had not given the resident medication yet that morning, so he had not yet received his hearing aids. During an interview with CNA #9 on 9/11/19 at 10:47 AM, she stated that nursing was responsible for putting in and taking out the resident's hear aids. The resident was up each morning and had breakfast in the dining room. She would notice if the hearing aids were not in. She thought they were in that morning. The surveyor and CNA observed the resident in his room, and he did not have his hearing aids in. During an interview with registered nurse (RN) #8 on 9/11/19 at 2:30 PM, she reviewed the resident's electronic record. She stated there was an order to ensure nursing was collecting the resident's bilateral hearing aids every night and applying them each morning. She stated it was documented the resident was to receive them at 8:00 AM and have them removed at 8:00 PM. She stated the hearing aids should be in as physician ordered. 2) Resident #107 was admitted to the facility on [DATE], most recently re-admitted on [DATE], with diagnoses including hard of hearing and depression. The 4/11/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, had moderate difficulty with hearing, did not have a hearing aid, felt depressed at times, liked to listen to music and keep up with the news, and required extensive assistance with most activities of daily living (ADLs). The 8/1/17, updated 4/17/19 and 8/23/19, comprehensive care plan (CCP) documented the resident had a hearing deficit, was at risk for social isolation, and was at risk for impaired communication. Interventions included refer to audiology as needed; speak slowly, clearly and loudly when facing the resident; ask resident to recap what was said to verify understanding; avoid yes/no answers; approach from front and use gentle touch to get her attention; sit resident close to front of activity or next to facilitator; monitor for change in participation; repeat communication if needed, staff to speak slowly, staff to speak clearly and loudly, avoid yes/no questions. The 1/25/19 physician order documented a hearing evaluation. The order was renewed on 4/26/19, 5/13/19, 6/13/19, 7/14/19, and 8/14/19. There was no documented evidence the hearing evaluation was completed. On 9/10/19 at 4:14 PM, the resident was lying in bed on her left side facing the doorway. She asked the surveyor to come to the left side of the bed as she was hard of hearing and that side was better for her to hear. She asked the surveyor to speak up and turn the TV off so that she could hear better. During an interview on 9/11/19 at 2:03 PM, the resident's family member stated a request for hearing aids was put in by the family 5 weeks ago. The resident stated she thought it was longer than that. When interviewed on 9/11/19 at 11:42 AM, certified nurse aide (CNA) #26 stated the resident was hard of hearing and did not have a hearing aid. She was not aware the resident wanted a hearing aid. When interviewed on 9/11/19 at 12:14 PM, registered nurse (RN) Unit Manager #27 stated she recently returned to the facility after an absence. She had asked audiology to see the resident prior to her absence and was not sure if that was done. She stated she had called the audiologist prior to leaving and did not document the conversation. She reviewed the resident's chart and stated there was no audiology consult in the chart. When interviewed on 9/11/19 at 2:40 PM, the Director of Nursing (DON) stated the audiologist was off-site and she was not aware of the resident having hearing issues. If there was a history of a resident being hard of hearing and had an audiology evaluation order, she expected the consult to be done within 30 days of notification to the audiologist. She expected nursing to have it scheduled, followed up on and put on the 24-hour report. She expected paperwork to be in the chart, and a progress note completed by the nurse calling the audiologist for an appointment. 10NYCRR 415.12(3)(b)

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, record review and interview during the recertification survey the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in ROM for 1 of 2 residents (Resident #106) reviewed for ROM. Specifically, Resident #106 was observed on multiple occasions without the recommended rolled wash cloth in her contracted hand. Findings include: The 1/2017 Preventative Care Measures and Care Requirements for Residents with Potential For, or Existing Contracture policy documented that when a contracture is identified it shall be evaluated by a physical therapist (PT) or occupational therapist (OT). The resident may be issued assistive devices. All assistive devices are to be used as tolerated. Resident #106 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (a neurological disorder) and dementia. The 8/15/19 Minimum Data Set (MDS) assessment documented that the resident had severely impaired cognition, required extensive assistance with activities of daily living (ADLs), and did not have functional limitation in upper extremities. The 11/26/18 OT progress note documented the resident did not want a right-hand splint, so staff were to utilize a rolled wash cloth in the resident's right hand. The wash cloth could be removed with skin checks and during routine care. Staff were to contact OT if the resident was not tolerating the wash cloth or if any skin issues developed. The comprehensive care plan (CCP), active in 9/2019, documented the resident was to utilize rolled wash cloths in bilateral hands, and they were to be removed for skin checks and hygiene care. The 8/27/19 certified nurse aide (CNA) [NAME] (care instructions) documented the resident was to utilize a right hand rolled wash cloth and was to be removed for skin checks and hygiene. The correlating ADL record had no documentation the resident refused or declined a device to her hand. The resident was observed without a wash cloth or contracture device in her right hand on 9/8/19 at 5:26 PM and 7:17 PM; on 9/9/19 at 9:30 AM; and on 9/10/19 at 8:36 AM and 12:26 PM. During an interview on 9/10/19 at 2:09 PM, CNA #21 stated she thought the wash cloth was to be used as tolerated. She did not put it in today because the resident usually did not like to wear it. She stated since the resident was not able to communicate, she knew the resident did like not to wear the wash cloth because the resident pulled it out. She stated that she did not put the wash cloth in the resident's right hand today. During an interview on 9/10/19 at 2:12 PM, licensed practical nurse (LPN) #22 stated according to the care plan the resident should have a rolled wash cloth in her right hand and she did not. The LPN stated she should be supervising to ensure the wash cloth was in place. During an interview on 9/11/19 at 10:20 AM, registered nurse (RN) Unit Manager #12 stated that she thought that PT wrote a revision note in 11/2018 that documented the rolled wash cloth in right hand should be used as tolerated, not routinely. She stated the revision was not made to the CNA [NAME]. She stated she expected staff to follow the [NAME] as instructed and if there were any issues then she should be notified. 10NYCRR 415.12(e)(2)

CONCERN (D)

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

Deficiency F0740 (Tag F0740)

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 the recertification survey the facility did not ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 5 residents (Resident #14) reviewed for mood and behavioral symptoms. Specifically, Resident #14 was not provided with psychological counseling as requested, and she exhibited behavioral symptoms. In addition, she did not have an individualized care plan to address her mood and behavioral symptoms. Findings include: The 3/2017 Outpatient Consultations policy documented the interdisciplinary team will determine if resident would benefit from psych (not specified if psychology or psychiatry) evaluation, follow up from contracted facility mental health service, or the need to reach out to a behavioral health care facility. The Administrator stated on 9/11/19 at 2:06 PM, the facility did not have a policy for referrals or use of the contracted facility mental health service. Resident #14 was admitted to the facility on [DATE] and had diagnoses including dementia, major depressive disorder and schizo-affective disorder. The 6/6/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, had frequent rejection of evaluation of care necessary to achieve the resident's goals for health and well-being, felt down, depressed, or hopeless and felt tired or had little energy. The resident rejected evaluation of care 4 to 6 days of the assessment period. The resident required extensive assistance for most activities of daily living (ADLs). A nursing progress note dated 5/16/19 documented the resident would be transferred to the hospital per nurse practitioner (NP) and recommendation of the psychiatrist. There were no corresponding nursing notes documenting behavioral concerns prompting discharge to the hospital. The 5/28/19 outside psychiatric facility discharge summary documented the resident had presented from the nursing facility with suicidal ideation and concern with care she was receiving at the facility. The resident would miss medications and she became paranoid. The plan was to follow up with psych and primary care providers. The 5/31/19 psychiatric consultation documented the resident had a schizoaffective disorder and dementia. She recently had complained of feeling depressed and voiced suicidal ideation with the intent of acting upon it. She was admitted back to the nursing facility from a psychiatric hospital. The resident had formerly been on trifluoperazine (antipsychotic) that was not available at the facility, so they started her on Abilify (antipsychotic) that was found not to be beneficial, and she became paranoid. When the psychiatrist approached the resident, she was adamant that she was not going to talk with a psychiatrist. The resident had a good rapport with the facility's NP and the interview took place with the NP present. The resident was mildly depressed and denied suicidal ideation. The psychiatrist recommended the resident continue the same anti-depressant and could be started on trifluoperazine. A 6/2/19 social services progress note documented the resident was re-admitted to the facility on [DATE] with new admission diagnoses of major depressive disorder and schizoaffective disorder. There was no documentation of plans for the resident's mental health concerns. There was no documentation by social services or another mental health professional between 6/3/19-9/8/19. A 6/3/19 nurse practitioner (NP) progress note documented she spoke with the resident regarding the use of the anti-depressant and the resident did not see an improvement, although the NP had. Nursing progress notes documented the resident had been on intense surveillance following re-admission on 5/28 through 6/7/19. There was no documentation what intense surveillance entailed. Nursing progress notes dated between 5/28-9/8/19 documented the resident occasionally refused medications, had concerns regarding her treatment, declined treatment, and had been monitored for the addition of an anti-depressant. The resident displayed anxiety and paranoia in 8/2019. The comprehensive care plan (CCP), active between 5/24-9/8/19, documented the resident refused medication, had potential for alteration in mood, resistive to care as evidenced by frequent medication/treatment refusals. The resident would attempt to hide medications and the nurse was to be present for all medication administration. The resident exhibited signs of socially inappropriate behavior and fabricating stories. The facility implemented interventions that included staff were to encourage taking medications, provide social services evaluation and follow-up; and when behaviors occurred ensure the resident was safe, leave the resident to calm, then-re-approach. Staff were to redirect negative behaviors, provide a consistent caregiver, notify the physician for changes, and provide 1:1 as needed (prn), provide emotional, psych prn, reduce environment, respect wishes for privacy, and validate feelings. The CCP did not include individualized interventions to address the resident specific significant and ongoing mood and behavioral symptoms. There was no documentation they re-evaluated the non-individualized interventions for effectiveness or implemented new non-pharmacological interventions to ensure the resident's psychosocial well-being was maintained. The 7/15/19 Referral Information Sheet to contracted facility mental health services documented that the resident was depressed and unhappy with her circumstances. A handwritten addition to the referral was dated 7/9/19 and documented the licensed clinical social worker (LCSW) attempted to visit the resident in her room and the resident declined to meet with the LCSW. There was no further information that the resident had been referred again or if another visit was attempted. The 8/15/19 registered nurse (RN) Unit Manager #8 progress note documented the resident told the NP that she would see the facility psychiatrist and the NP would set up the appointment. There was no further documentation that the resident had been referred to the psychiatrist. The 9/8/19 certified nurse aide (CNA) instructions had no documentation regarding potential resident mood or behavioral symptoms or interventions for direct care staff to use with the resident. The CNA instructions were updated on 9/9/19 and noted see nurse for behavioral interventions. During an interview with the resident on 9/8/19 at 5:07 PM, she stated she had asked social services for counseling services. She was aware she had anxiety and paranoia and wanted assistance with these symptoms. During an interview on 9/11/19 at 9:33 AM, certified nurse aide (CNA) #26 stated resident specific interventions were not documented on the CNA assignment sheets and they were known by working with the residents. She worked with the resident everyday because the resident did not like one of the other regular CNAs. The resident had a lot of behaviors, she would claim things were stolen on the night shift, she was paranoid at times, and she had a lot of ups and downs. She would argue with staff and the resident had hurt her feelings recently. During an interview on 9/11/19 at 10:12 AM, registered nurse (RN) acting Unit Manager #8 stated the resident did not make accusatory statements towards staff, she had a lot of mental illness, and she got worked up at times. She would fixate on something, and redirection and reapproaching did not always work with her. She went to the hospital on 9/9/19 for a psychiatric evaluation and she returned and had not had behaviors since. She had agreed to see the facility psychiatrist, he had just returned from vacation, and she was planned to see him the following week; she was last scheduled to see the psychiatrist in 4/2019 and she had refused to see him. Counseling services were available at the facility from family services and she refused to see them as well. The Director of Social Work saw the resident and sometimes it was documented. When asked about the 8/15/19 progress note, the RN stated that the psychiatrist was on vacation at that time, so the resident was not seen. During an interview on 9/11/19 at 10:50 AM, the Director of Social Services stated the resident would refuse medications and would spiral and had gone to the hospital the other day. The social worker was teaching the resident how to knit which helped to calm the resident's mind. The resident had become more involved with activities until her recent decline in mental health status. She visited the resident often and did not always document her visits with the resident due to lack of time. The resident's husband had stopped visiting as much because the resident was difficult with him and the family. The resident had counseling available through family services and she had refused them in the past as well as the psychiatrist's services. During an interview on 9/11/19 at 11:43 AM, nurse practitioner #36 stated she tried to use as few medications as possible, and psychiatric services were available through the psychiatrist. The resident had paranoia and sadness. Counseling was provided through family services, and she said the counselors should be documenting their visits. The resident had agreed to see the psychiatrist on 9/16/19. The last time the resident refused to talk to the psychiatrist directly and the NP had to be present for the visit. In 8/2019, the resident had agreed to see the psychiatrist and he was on vacation at that time. On 9/9/19, the resident was paranoid, having a tough time, and the NP was unable to calm her down. The resident had a longstanding history of schizoaffective disorder, they had to wean her off trifluoperazine (typical antipsychotic for the treatment of schizophrenia) due to lack of medication availability, the medication became available again and the resident was back on it. The NP stated she did not think they would be able to stabilize the resident. The NP had encouraged the resident to write poetry in the past and that was a good outlet for the resident. On 9/11/19 at 1:07 PM, documentation from the counseling services included a letter stating the resident was participating in a cognitive program, the resident had been referred to counseling services in the past for evaluation and treatment of behavioral and mood symptoms, and the resident had declined any individual evaluation for counseling purposes. During an interview on 9/11/19 at 1:30 PM, the family services counselor #39 stated they were able to provide counseling by a licensed professional. The resident participated in Mind Aerobics which was a cognitive program for people with dementia which could improve depression. She stated the resident declined counseling at least once in the past and she did not know if it had been offered again. 10NYCRR 415.12(f)(1)

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, there were spoiled items found in the walk-in produce cooler and soiled/unclean pots and pans found on the clean drying rack. Findings include: During an observation on 9/8/19, between 4:15 PM and 4:51 PM, the main kitchen walk-in produce cooler contained: - a bin of damaged/moldy peppers; - a bin of beets with 10 peeled turnips in it; - a milk crate of cauliflower containing 3 heads which had mold on them; - a bag of spinach that was spoiled; and - a bag of basil that was spoiled. During an interview on 9/8/19 between 4:15 PM and 4:51 PM, the Food Service Director stated if he was not at the facility a Food Service Manager was supposed to check the kitchen, including checking for spoiled items in the walk-in coolers. During an observation on 9/9/19 at 12:08 PM, the main kitchen clean drying rack contained 4 pans and 3 pots that were soiled/unclean and one empty coffee carafe that had 3 dead fruit flies in it. During an observation on 9/10/19 at 8:33 AM, the sink in the unit 1 kitchenette had unclean tiles and there was brown splatter on the wall below the sink. On 9/10/19 at 9:45 AM, a family member of an unidentified resident stated the kitchenette and dining room needed cleaning. The pantry closet and the drink area were often unclean and there were napkins on the floor. The pantry closet in the kitchenette had not been cleaned since her family member was admitted to the facility. On 9/10/19 at 12:06 PM, the kitchenette on the Terrace unit was observed. There was food debris on the steam tables on the breakfast side. There was food splattered on the dolly for the garbage. The floor of the dining room was sticky and had dried streaks of unclean mop water; the surveyor's shoes were sticking to the floor and the shoes of staff could be heard sticking to the floor as they walked. A food service worker brought out a stack of clean plates. The plates were resting against his chest and his chin was an inch above the top plate and he was breathing on the plates. There was food debris on the kitchenette floor around the drain and crumbs on the counter by the toaster. On 9/10/19 at 12:09 PM, the closet in the Terrace dining room was observed. There was a plastic knife, 2 paper placemats, a straw, a metal hanger, a blue stain, and unclean water stains on the floor of the closet. On 9/10/19 at 12:24 PM, the condiment tray on the Terrace unit was observed. There was food debris at the bottom of the condiment tray, pepper on the tartar sauce packets, and a sticky substance spilled on the side. On 9/11/19 at 9:14 AM, the closet in the Unit 1 dining room was observed. There was a sugar packet and a straw on the floor. During an interview on 9/11/19 at 3:32 PM, the Food Service Director stated the entire management team from the contracted food service company, should check pots/pans and the drying rack daily during rounds. The management team included the Food Service Director, the Operations Manager and the executive chef. Any spoiled food items found by kitchen staff should be immediately discarded. 10NYCRR 415.29(j)(1)

CONCERN (D)

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

Deficiency F0836 (Tag F0836)

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 the recertification survey, the facility did not ensure services were provided in compliance with all applicable Federal, State, and local laws, regulations, and codes for 2 of 3 (Residents #29 and 106) reviewed for advance directives. Specifically, Residents #29 and 106 had Medical Orders for Life Sustaining Treatment (MOLST) completed by a health care proxy (HCP, a person designated to make health care decisions for someone determined to have a lack of capacity for decision-making) and did not have a determination of incapacity completed by a physician or nurse practitioner (NP) and a concurring physician or NP prior to the implementation of health directives as required by New York State Law. Findings include: The undated Establish Advance Directives policy documented a resident's decision-making capacity will be assessed by Social Services who will conduct the Brief Interview for Mental Status (BIMS). When the BIMS shows that he/she is without capacity 2 physicians document this information on form 1003 and placed in the advance directive section of the chart. Social services will make note of advance directive information and decision-making capacity in residents' progress notes and care plan section under monitoring and evaluation notes. 1) Resident #29 was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbance. The 6/13/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired. The MOLST signed by the resident's HCP and the NP on 9/20/18 documented Do Not Resuscitate (DNR, do not attempt resuscitation, allow natural death), comfort measures only, do not send to the hospital unless severe symptoms cannot be otherwise controlled, no feeding tube or intravenous fluids, and determine use or limitations of antibiotics when infection occurs. There was no documentation that the resident had a determination of incapacity completed by the physician or NP and had a concurring determination of incapacity by the physician or NP. 2) Resident #106 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a neurological disease) and dementia. The 8/15/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired. The MOLST signed by the resident's HCP and the NP on 6/21/19 documented Do Not Resuscitate (DNR, do not attempt resuscitation, allow natural death), comfort measures only, do not send to the hospital, no feeding tube, and determine use or limitations of antibiotics when infection occurs. There was no documentation that the resident had a determination of incapacity completed by the physician or NP and had a concurring determination of incapacity by the physician or NP. When interviewed on 9/11/19 at 3:50 PM, registered nurse (RN) Unit Manager #12 stated the Director of Social Services filled out the capacity forms and the Unit Manager just signed as a witness on MOLST order forms. When interviewed on 9/11/19 at 3:57 PM, Director of Social Services #13 stated she coordinated getting capacity forms completed. She stated when the residents were admitted she had forgotten to complete the forms. 10NYCRR 415.3(e)(1)(ii)

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation and interview during the recertification survey, the facility did not maintain a clean and home-like environment for 3 of 3 nursing units (Units 1, 2 and Terrace). Specifically, the floors of the dining rooms on all three units were observed to be sticky and the walls were unclean. Findings include: On 9/8/19 at 5:55 PM, the dining room floor on Unit 2 was sticky. The surveyor's shoe stuck to the floor when she walked and nearly pulled her shoe off her foot. On 9/8/19 at 6:14 PM, the dining room floor on Unit 1 was sticky by the door to the kitchenette. The floor appeared unclean. On 9/10/19 at 8:33 AM, the sink in the Unit 1 kitchenette had unclean tiles and there was a brown splatter on the wall below the sink. On 9/10/19 at 12:06 AM, the kitchenette on the Terrace Unit was observed. The floor of the dining room was sticky and had dried streaks of unclean mop water. The surveyor's shoes stuck to the floor and the sound of staff shoes sticking to the floor as they walked was heard. On 9/10/19 at 12:09 PM, the closet in the Terrace Unit dining room was observed. There was a plastic knife, 2 paper placemats, a straw, a metal hanger, a blue stain from a food label, and unclean water stains on the floor of the closet. On 9/10/19 at 12:24 PM, the condiment tray on the Terrace Unit was observed. There was food debris at the bottom of the condiment tray, pepper on the tartar sauce packets, and a sticky substance spilled on the side. On 9/10/19 at 12:44 PM, the door to the left side of the Terrace Unit dining room and main dining area was observed with splatters on the door up to the window and with chips on the edge closest to the door frame. On 9/11/19 at 9:14 AM, the closet in the Unit 1 dining room was observed. There was a sugar packet and a straw on the floor. During an interview on 9/11/19 at 9:55 AM, the Director of Facilities stated the pantry and kitchenette were supposed to be cleaned/maintained by the kitchen staff. Maintenance and Housekeeping were responsible for the dining room area. The dining room floors were cleaned and mopped 3 times a day after each meal. The sticky floors were due to a wax issue, and the floor wax was last stripped in 3/2019. The Terrace Unit and Unit 1 closets were cleaned two months ago after an odor complaint. During an interview on 9/11/19 at 10:46 AM with Director of Housekeeping #30, he stated the kitchen area floors were sticky due to the type of disinfectant cleaners that were being used on the evening shift when they cleaned the floors. He stated he was aware of the situation and that right now the floors were only stripped and buffed a few times a week. He stated that a neutralizer should have been used on the floor. He consulted with Assistant Director of Housekeeping #32 who also stated he was aware of the sticky floors. He also stated that the disinfectant was causing the floors to be sticky. He stated that the floors needed to be stripped with a neutralizer more often than they were. During an observation on 9/11/19 at 1:35 PM of the kitchen floor on Unit 2, the facility staff had already mopped the dining room floor and the floor was sticky and shoes were sticking to the floor. During an interview on 9/11/19 at 1:39 PM with housekeeper #31, she stated that Director of Housekeeping #30 had been aware of the sticky floor. She stated she had complained to him many times. She mopped the kitchen floor on Unit 2 daily in the afternoon and it was sticky every day after she mopped. She stated she thought it was caused by the cleaning disinfectant the evening shift was using on the floor. During an interview on 9/11/19 at 2:05 PM, the Housekeeping Supervisor stated the walls for the dining rooms were cleaned daily and as needed. The floors were cleaned three times a day after every meal. He was aware of the sticky floors. The current floor chemical had been used for a month. The wax brand was replaced about 9 months ago. Floors within the dining room closets were cleaned when the floors were refinished (stripped and waxed). The shelves in those closets were maintained by the kitchen staff. The kitchen staff was responsible to pickup/clean anything that fell from the shelves. There was no specific reference to cleaning floors and walls on the current daily cleaning sheet. He was not aware that the walls were not clean in the Terrace dining room. During an interview with housekeeper #38 on 9/11/19 at 10:37 AM, he stated the cleaning product the facility had for the floors caused the floors to be sticky if too much of the product was dispensed. He stated the Terrace Unit required extra mops and cleaning after meals. During an interview on 9/11/19 at 2:57 PM, the Food Service Supervisor stated the server was supposed to check that the closet was clean, organized and stocked every shift. 10NYCRR 415.5(h)(1)(2)

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 3 of 4 meals (first floor lunch, terrace floor lunches) tested. Specifically, food during the lunch meals on first floor and terrace floor were not served at palatable temperatures. Findings include: The 8/2009 procedure provided by the facility for their food contract company documented hot product holding temperatures must be maintained at 140 degrees Fahrenheit (F) or above while holding and serving. Cold product holding temperatures must be maintained at 40 degrees or below while holding and serving. The 9/6/19 Resident Council Meeting Minutes documented 1 resident stated her food arrived cold. During an interview on 9/8/19 at 4:57 PM, Resident #14 stated the food was not good. During an interview on 9/9/19 at 9:57 AM, Resident #25 stated the food was not good. During an interview on 9/9/19 at 10:25 AM, Resident #114 stated hot foods were cold by the time they were served. She stated the taste of the food was not good and she mostly ate food her family brought in. During the 9/10/19 at 10:32 AM Resident Council Meeting, 1 resident stated the taste and temperature of the food was not acceptable. On 9/9/19 at 1:11 PM, during a Unit 1 lunch test tray obtained from the steam table and serving area, the following temperatures were observed: - the chicken salad with peas was 47 F; - a hamburger was 121 F; and - the mashed potatoes were 99 F. The Food Services Supervisor #5 was present at the time of the observation and concurrently verified the temperatures taken by the state thermometer. On 9/10/19 at 1:00 PM, a lunch tray was tested in the presence of Food Services Supervisor #5. The ambrosia salad was 59.9 degrees on the state thermometer and 58.3 degrees on the facility thermometer. The cubed chicken in the sauce was 107 degrees F on the state thermometer and 111 degrees on the facility thermometer. The edge on the scoop of ambrosia salad had started to melt in the cup and the chicken did not feel warm. During an interview on 9/10/19 at 1:00 PM, Food Service Supervisor #5 stated she was unhappy with the temperatures of the chicken and the ambrosia temperature was higher than she would like. On 9/11/19 at 3:14 PM, Food Service Supervisor #5 stated the hot holding temperatures should be 140 F or above. She did not consider a hamburger at 121 F or potatoes at 99 F acceptable temperatures. The dietitian completed three test trays monthly, and supervisors completed several test trays a month. Trays were taken at the end of meals. She had not seen or been told of any temperature issues for meals. She was not sure if there were any policies to tell staff to set the steam tables on high prior to serving. On 9/11/19 at 10:55 AM, dietary aide #4 was observed pouring apple juice at Resident #122's table for lunch. On 9/11/19 at 12:08 PM, Resident #122 was brought to the table where his apple juice had already been placed. The surveyor obtained a temperature of the apple juice at 65.4 degrees with Food Service Supervisor #5 present. She stated drinks should be served under 40 degrees. During an interview 9/11/19 at 12:10 PM, dietary aide #4 stated drinks should be served at 40 degrees and he just found that out. He was trying to get caught up on his tasks, had not taken a break yet, and wanted to get lunch service started. He stated serving drinks warmer than 40 degrees affected the enjoyability of the drink. 10NYCRR 415.14(d)(1)(2)

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, record review and interview during the recertification survey the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the main laundry area; and for 1of 3 residents (Resident #29) reviewed for pressure ulcers. Specifically, improper infection control technique was observed during a pressure ulcer treatment observation for Resident #29. Additionally, there was no evidence of personal protective equipment (PPE) in the wash area of the laundry room, and washer and dryers were not maintained per manufacturer's guidelines. Findings include: 1) Resident #29 was admitted to facility on 5/14/18 with diagnoses including Stage 4 (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone) pressure ulcer of the left buttock and dementia. The 6/13/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment; required extensive assistance with most activities of daily living (ADL) and had one Stage 4 pressure ulcer. The facility infection control manual documented under Personal Protective Equipment (PPE) that gloves should be changed (and hands washed) between tasks and procedures on the same resident after contact with any material that may contain a high concentration of microorganisms. The 6/22/18 comprehensive care plan (CCP) documented the resident had a pressure ulcer and the wound would be free of signs and symptoms of infection. The September 2019 treatment administration record (TAR) documented to cleanse the wound on the left buttock with normal saline, apply Santyl (removes dead tissue) topical ointment nickel thick layer to the entire wound bed including inside tunnel, pack firmly with rolled gauze damp with 1/4 strength Dakin's (antiseptic) solution every day. On 9/10/19 at 10:55 AM a treatment of the resident's wound was observed with licensed practical nurse (LPN) #22. LPN #22 gathered supplies from the treatment cart and laid them on top of the clean linen cart with no barrier between supplies and the linen cart. She applied gloves and cleansed the wound with normal saline. She did not change her gloves or perform hand hygiene and proceeded to apply the new wound dressing. During an interview with LPN #22 on 9/10/19 at 11:05 AM, she stated the expectation of the facility was to provide wound care per order on the TAR. She was aware that she did not place a barrier down or change her gloves and perform hand hygiene after cleansing the wound and prior to performing the wound treatment. She stated the wound could be contaminated. During an interview on 9/10/19 at 12:03 PM with registered nurse (RN) Unit Manager #12, she stated that the facility expectation was supplies should always be placed on a barrier when performing wound care. She stated after a wound was cleansed, hand hygiene should be perfomed and gloves should be changed. Not performing hand hygiene or changing gloves could contaminate the wound and increase the chance of infection. During an interview on 9/11/19 at 11:39 AM with Infection Control RN #40, she stated the expectation was a clean barrier should be placed, and the supplies should be placed on the barrier to keep them clean. She stated she did not understand why gloves had to be changed and hand hygiene had to be performed when cleansing the wound. 2) During an interview on 9/11/19 at 1:01 PM, the Director of Facilities stated the washers and dryers were not maintained as per the user manual, he could not find the user manuals for all the washers and dryers and he could not find a facility policy for the maintenance of the washers and dryers. During an observation in the main laundry room on 9/10/19 at 10:11 AM there was an area in the laundry room that had no personal protective equipment (PPE) available. There were no gowns or goggles observed. Laundry Room worker #41 stated that she had goggles and a gown at the sink but was unable to locate them and not sure what had happened to them. During an interview on 9/11/19 at 9:54 AM with the Director of Housekeeping, he stated that the facility expectation was that all infectious laundry was placed in red bags from the units and brought down to the laundry area. Prior to the laundry being handled the staff must put on PPE. He stated the goggles were disposable because of dry rot on the band and he did not know why they were not replaced. He stated that he had placed gowns in the area and maintenance was placing hooks so the goggles could be hung and not get misplaced. During an interview on 9/11/19 at 10:09 AM with laundry worker #41, she stated the facility expectation was that when infectious or heavily soiled laundry came down from the units was expected to carry the laundry away from her body and wear PPE. She stated she did not know what happened to the goggles or the gowns at the wash station and did not know how long they had been missing. 10NYCRR 415.19

CONCERN (E)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not maintain an effective pest control program for the main kitchen and 3 of 3 units (Units 1, 2 and Terrace). Specifically, there were pest control issues (small flies) observed on Units 1, 2 and Terrace. Findings include: Small flies were observed in the following areas: -On 9/8/19 at 5:18 PM, the first unit dining room, serving area, kitchenette and hall outside the pantry area; -On 9/8/19 at 5:55 PM, the first unit Ridge spa room; -On 9/8/19 at 6:07 PM, the second unit Lane spa room and the hall near the spa room; -On 9/8/19 at 6:18 PM, the second unit dining room, serving area and kitchenette; -On 9/8/19 at 6:30 PM, the second unit Ridge spa and the second unit Ridge hall near the laundry room; -On 9/8/19 at 6:34 PM, the terrace unit hall outside the pantry and the hall near the laundry room; -On 9/8/19 at 7:00 PM, the Terrace unit dining room; -On 9/9/19 at 10:18 AM, the Terrace unit hall near resident room [ROOM NUMBER]; -On 9/9/19 at 10:35 AM, the Terrace unit nursing station; -On 9/9/19 at 11:40 AM, the second unit dining room and the second unit kitchenette; -On 9/9/19, between 12:15 PM and 1:30 PM, the first unit family conference room; -On 9/9/19 at 12:27 PM the first unit dining room, serving area and kitchenette; -On 9/9/19 at 3:56 PM, the Terrace unit hall near room [ROOM NUMBER]; -On 9/10/19 at 6:57 AM, the Terrace unit near the front lounge; -On 9/10/19 at 7:59 AM the second unit dining room, serving area and kitchenette; and -On 910/19 at 8:15 AM the second unit hall near the laundry room. During an interview 9/10/19 at 9:35 AM, food service worker #29 stated he had been working permanently on the second unit for approximately 6 months, and there had been small flies on this floor for entire time. In the last year while covering the second unit there had been small flies on the unit. The maintenance department would pour a drain cleaner down the drains monthly. During the summer there were more small flies and they usually would congregate close to water and areas with less motion. He had observed small flies on all three resident floors, including the serving areas. On 9/10/19 at 12:10 PM, food service worker #28 was observed shooing a fly away from the lunch food on the steam tables. During an interview on 9/10/19 at 12:10 PM, food service worker #28 stated all three resident floors had small flies on them, and he had seen them since he was hired in 2018. Concurrently, he was observed swatting small flies away from his face while prepping for food service. During an observation on 9/10/19 at 12:15 PM, the following Terrace unit dining room, serving area and unit kitchenette areas had small flies. During an interview on 9/11/19 at 9:55 AM, the Director of Facilities stated he was not aware of the flies on the resident units. He was aware that the main kitchen has had small flies in the past and was not aware of small flies in the First Unit Ridge spa room. He stated a degreaser/deodorizer had been poured down the drains on resident floors since he was hired in 2018. During interview on 9/11/19 at 3:21 PM, the Operations Manager stated she was aware of the small flies on the resident floors. They have been seen off and on for at least a year. When she would see the flies, she would immediately clean the area, and then contact maintenance. She would walk with pest control company when they came monthly for inspections. Pest control walked the main kitchen, and all three kitchenettes. During June and August walk through there were no small flies observed. Pest control logs from 6/26/19 to 8/28/19 documented small flies were not present on 8/28/2019. There was documented sightings of small flies on the first unit and Terrace unit on 7/24/2019. 10NYCRR 415.29(j)(5)

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

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $132,140 in fines. Review inspection reports carefully.
• 47 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $132,140 in fines. Extremely high, among the most fined facilities in New York. Major compliance failures.
• Grade F (3/100). Below average facility with significant concerns.

Bottom line: Trust Score of 3/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Jewish Home Of Central New York's CMS Rating?

CMS assigns JEWISH HOME OF CENTRAL NEW YORK 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 Jewish Home Of Central New York Staffed?

CMS rates JEWISH HOME OF CENTRAL NEW YORK's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the New York average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Jewish Home Of Central New York?

State health inspectors documented 47 deficiencies at JEWISH HOME OF CENTRAL NEW YORK during 2019 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 45 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Jewish Home Of Central New York?

JEWISH HOME OF CENTRAL NEW YORK 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 132 certified beds and approximately 114 residents (about 86% occupancy), it is a mid-sized facility located in SYRACUSE, New York.

How Does Jewish Home Of Central New York Compare to Other New York Nursing Homes?

Compared to the 100 nursing homes in New York, JEWISH HOME OF CENTRAL NEW YORK's overall rating (1 stars) is below the state average of 3.0, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Jewish Home Of Central New York?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.

Is Jewish Home Of Central New York Safe?

Based on CMS inspection data, JEWISH HOME OF CENTRAL NEW YORK has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in New York. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Jewish Home Of Central New York Stick Around?

Staff turnover at JEWISH HOME OF CENTRAL NEW YORK is high. At 56%, the facility is 10 percentage points above the New York average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Jewish Home Of Central New York Ever Fined?

JEWISH HOME OF CENTRAL NEW YORK has been fined $132,140 across 3 penalty actions. This is 3.8x the New York average of $34,400. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Jewish Home Of Central New York on Any Federal Watch List?

JEWISH HOME OF CENTRAL NEW YORK 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: 132
Avg. Residents: 114
Occupancy: 86.8%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
1 Actual Harm citation: -5
47 Deficiencies: -10
Fines ($132,140): -15
Final Score: 3/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 335190