Schoellkopf Health Center

Based on observation, interview, and record review conducted during a Standard survey completed on 08/22/2025, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #45) of one (1) resident reviewed. Specifically, Resident #45 was observed with medication in their room. Self-administration was determined through interviews despite the lack of an assessment to determine the resident's ability to safely do so. The finding is: The policy titled Self-Administration of Medications undated, documented residents have the right to self-administer medications if they choose and the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Resident #45 had diagnoses that included chronic obstructive pulmonary disease (COPD-lung disease), congestive heart failure (chronic heart condition), and atrial fibrillation (irregular heart rate). The Minimum Data Set (a resident assessment tool) dated 05/11/2025 documented Resident #45 was cognitively intact.The Comprehensive Plan of Care, reviewed 08/11/2025, documented Resident #45 was at risk for cerebral vascular event and cardiac/respiratory distress. Approaches included to administer medications/treatments per medical doctor orders, monitor for and report any possible adverse effects. The comprehensive plan of care did not reflect Resident #45's ability to self-administer medications.Review of the Active Order Profile documented an active physician's order dated 05/28/2024 for Albuterol (medication used to open airway and make breathing easier)90 micrograms/inhaler inhalation aerosol, 180 micrograms inhalation every four (4) hours as needed for wheezing. There were no physician's orders for Resident #45 to self-administer medications or to leave medications at the bedside. Review of the Medication Administration Record dated 06/01/2025-08/20/2025 documented Resident #45 received Albuterol 90 micrograms/inhaler inhalation aerosol 180 micrograms on 08/20/2025 at 10:30 AM. There was no other documented evidence that Resident #45 had received the albuterol inhaler as ordered. Review of progress notes- nurse dated 06/01/2025 to 08/21/2025 revealed there was no documentation that Resident #45 was self-administering albuterol inhaler and the Albuterol inhaler was kept at their bedside. During an observation on 08/19/2025 at 11:30 AM, an albuterol inhaler was observed on Resident #45's tray table at bedside. During an observation and interview on 08/20/2025 at 9:15 AM, Resident #45 had an Albuterol inhaler in their room, on their lap. Resident #45 stated they took the Albuterol inhaler every four (4) hours as needed but had been taking it more frequently due to swelling. Resident #45 could not specify how frequently they were using the Albuterol inhaler daily. They stated they had used, the Albuterol inhaler that morning before their shower and again after their shower. Resident #45 stated the nurses were aware that they used the inhaler frequently but did not ask them about when they used it or why they used it. Additionally, Resident #45 stated the nurses reordered the Albuterol inhaler for them and allowed them to keep it in their room. During an interview on 08/20/2025 at 10:33 AM, Licensed Practical Nurse #5 stated they were aware that Resident #45 had an albuterol inhaler at their bedside. They stated they removed it from Resident #45 that morning because they couldn't have the Albuterol inhaler at their bedside without a physician's order. Licensed Practical Nurse #5 stated they did not know how frequently Resident #45 was self-administering their inhaler, as it was not documented. Licensed Practical Nurse #5 stated it needed to be determined if a resident was alert enough, and able to self-administer medications before medications were left at a bedside. During an interview on 08/22/2025 at 9:23 AM, Registered Nurse #3 stated residents need to be evaluated to self-administer medications, must be reviewed with the physician and documented. They stated it was important for residents to be evaluated for safety. Registered Nurse #3 stated Resident #45 had not been evaluated to self-administer medications and was not to have medications at their bedside. During a telephone interview on 08/22/2025 at 11:46 AM, Licensed Practical Nurse #7 stated residents needed a physician's order to be able to keep medications at their bedsides. They stated that Resident #45 kept an Albuterol inhaler at their bedside and thought they had an order to do so. Licensed Practical Nurse #7 stated they were not aware of any monitoring for self-administering of medications and that the use of bedside medications was not documented to their knowledge. Additionally, Licensed Practical Nurse #7 stated they reordered Resident #45's Albuterol inhaler when low, so Resident #45 would not run out of it. During an interview on 08/22/2025 at 12:35 PM, the Director of Nursing stated they expected residents to be evaluated for the ability to self-administer medications. They stated residents need to be evaluated for safe handling of medications including knowing what they were taking, why, and how often. They stated there needed to be accountability for what medications residents were taking to ensure proper use and safety. 10 NYCRR 415.3 (f)(1)(vi)

Based on observation, interview, and record review conducted during a Standard Survey completed on 08/22/2025, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 1 (one) (Resident #126) of 2 (two) residents who were reviewed for activities of daily living. Specifically, Resident #126 was not assisted/provided with nail care and was observed with dirty long jagged fingernails. The finding is:The undated policy and procedure titled Nail Care documented that nails are observed daily by staff providing direct care. Nails are to be inspected weekly by a nurse and CNA on bath day and trimmed as indicated. The procedure included but was not limited to gently cleaning under nails with an orange stick, trimming with nail clippers, clipping nails straight across, and shaping nails with a nail file as needed.The policy and procedure titled Activities of Daily Living revised 03/2011 documented that residents are provided with care, treatment, and services as appropriate to maintain the ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.Resident #126 had diagnoses of dementia, orthostatic hypotension (a sudden drop in blood pressure when standing up), and chronic pain. The Minimum Data Set (a resident assessment tool) dated 06/16/2025 documented Resident #126 was moderately cognitively impaired. The resident required partial to moderate assistance for personal hygiene.The Comprehensive Care Plan dated 06/20/2025 documented that Resident #126 required limited assistance x1 (one) with grooming. The resident had no behavioral issues. Resident #126 was at risk for alteration in skin integrity. Interventions included to assesses skin weekly during bath/shower and showers were to be completed per schedule. Review of a document titled Single Patient Task List - Scheduled Patient Care for Resident #126 documented that weekly skin evaluations on shower days were to be completed on Mondays on the 3:00 PM-11:00 PM shift. During an observation on 08/18/2025 at 9:40 AM, Resident #126 was up and dressed sitting in their wheelchair. The resident's fingernails were long (approximately 1/2 inch long beyond their fingertips), jagged, and had chipped nail polish. During an observation on 08/19/2025 at 8:56 AM, Resident #126 was in bed eating breakfast. Their fingernails were long (approximately 1/2 inches long beyond their fingertips), jagged, with debris noted at the base of their fingertips.During an observation on 08/20/2025 at 9:00 AM Resident #126 was in the television room. their fingernails remained long (approximately 1/2 inches long beyond their fingertips), were jagged, had chipped nail polish and debris was noted at the base of their fingertips.During an observation on 08/21/2025 at 11:01 AM, Resident #126's fingernails were long and jagged with chipped nail polish. The resident's palms were red and irritated, with an intact fluid-filled, purplish blister about 1/2 inch long in the center of the left palm, and another open blister about 1/4 inch noted on the same palm.During an attempted interview on 08/18/2025 at 9:40 AM, Resident #126 was confused and appeared anxious. They attempted to show their palms of their hands, which appeared pink, irritated, and blistered. Licensed Practical Nurse #2 approached and asked if the resident's hands were bothering them. The resident stated they did not know what was happening and showed the nurse their palms. Licensed Practical Nurse #2 stated the resident had contact dermatitis (a skin rash due to contact of a substance) and that they would administer Benadryl. During an interview on 08/20/2025 at 11:39 AM, Licensed Practical Nurse #1 stated Resident #126 got their nails painted during activities, but it was the Certified Nursing Aides' responsibility to clean, file, and trim them. Licensed Practical Nurse #1 stated the resident had contact dermatitis and had a new order that required their hands be always covered, but the Certified Nursing Aide did not inform them that morning care was completed. During an interview on 08/22/2025 at 9:24 AM, Certified Nursing Aide #2 stated when they performed morning care, they cleaned, trimmed, and filed nails if needed, but this was usually done on shower days. They stated the importance of keeping residents' nails cleaned, trimmed, and filed was to prevent accidental scratching. During an interview on 08/22/2025 at 11:38 AM, Manager Registered Nurse #1 Unit Manager stated they assisted with showering Resident #126 that morning and cleaned the resident's nails but did not trim them, believing it was best not to disturb skin on the hands. Registered Nurse #1 acknowledged they did not file the resident's nails and stated they should have because they were jagged. They emphasized the importance of keeping residents' nails cleaned, trimmed, and filed, as some residents eat with their hands. They further stated nails can harbor bacteria and increase the risk of infection. 10 NYCRR 415.12 (a) (3)

Based on interview and record review conducted during the Standard survey completed on 8/22/2025, the facility did not provide services consistent with professional standards of quality for one (1) (Resident #119) of one (1) resident reviewed for change in condition. Specifically, Resident #119, who had a recent history of seizures, did not receive Levetiracetam (anti-seizure/anti-convulsant medication) as ordered by the physician and the physician was not notified of the omission.The finding is:The policy titled Unavailable Medication last revised 09/27/2016 documented that residents would receive necessary medications as ordered by the physician, if medications were not available the physician would be notified and would adjust medications accordingly. The nurse would indicate on the MAR (medication administration record) that drug was not given and document that physician was notified and when indicated the directive for alternate administration time or medication. The nurse would notify the pharmacy of unavailable medication and notify supervisor. The nurse must document on the 24-hour report sheet that medication was missed to allow for a follow up resolution.Resident #119 had diagnoses that included seizure disorder, history of cerebrovascular accident (stroke), and dementia. The Minimum Data Set (a resident assessment tool) dated 06/06/2025 documented Resident #119 was moderately cognitively impaired, sometimes understood, sometimes understands and received anti-convulsant medication.The comprehensive care plan dated 06/20/2025 documented Resident #119 was at risk for falls related to their seizure diagnosis with interventions to give medications as ordered; monitor and report any adverse effects.The closet care plan (a guide used by staff providing care) dated 06/20/2025 documented Resident #119 required two staff assist with mechanical lift for transfers, was non ambulatory, a total assist of one staff member for bed mobility and had a safety intervention in place for seizure precautions.The physicians' orders dated 08/21/2025 documented Resident #119 had an active order dated 05/21/2025 to administer Levetiracetam 750 (seven hundred and fifty) milligrams (mg) by mouth twice a day (BID).Review of nursing progress notes dated 07/29/2025 at 2:49 PM and 07/29/2025 5:00 PM revealed Resident #119 experienced two separate seizures, one lasting 6 minutes in length where Resident #119 became unresponsive. Review of the Medication Administration Record dated 07/31/2025 revealed Levetiracetam 750 milligrams by mouth was not administered by Licensed Practical Nurse #4 to Resident #119 at 5:34 PM due to the medication not being available.Review of facility identified 24-hour report sheet dated 07/31/2025 revealed there was no documented evidence that the nursing supervisor or physician were updated on Resident #119s missed dose of Levetiracetam.Review of nursing progress notes dated 07/31/2025 revealed there was no documented evidence that the physician was updated on Resident #119s missed dose of Levetiracetam.During a telephone interview on 08/21/2025 at 9:19 AM Licensed Practical Nurse #4 stated they were unfamiliar with Resident #119 and had floated down from a different unit on 07/31/2025, went to administer Resident #119s Levetiracetam, and did not see it in the cart. Licensed Practical Nurse #4 stated they alerted Registered Nurse #4 Nursing Supervisor who said they would call the pharmacy to see if it was due to be delivered soon. Licensed Practical Nurse #4 stated the medication had not been delivered by the end of their shift and they did not check on it. They stated they should have checked up the situation prior to leaving for the day.During a telephone interview on 08/21/2025 at 9:25 AM, Pharmacy Consultant #1 stated they did not think that missing one dose of Levetiracetam would cause a person to have a seizure, but it potentially could. Pharmacy Consultant #1 stated the physician should have been updated on Resident #119s missed dose, seizure medication like Levetiracetam was important, and the pharmacy should have been contacted as well.During an interview on 08/21/2025 at 9:29 AM, the Director of Nursing stated the facility protocol for when a medication was not available was to notify the supervisor, who would notify the physician for further orders, and all would be documented. The Director of Nursing stated they would have expected Licensed Practical Nurse #4 to have documented that the supervisor and physician were updated on Resident #119s missed dose and document any new orders, if some, based on what the provider said and significance of the medication.During a telephone interview on 08/21/2025 at 10:02 AM, Medical Director #1 stated they were not updated on Resident #119 missing a dose of their Levetiracetam on 07/31/2025 and would have expected to have been updated on the missed dose; they had been updated that Resident #119 had multiple seizures two days prior. Additionally, Medical Director #1 stated it was possible Nurse Practitioner #1 was updated if Medical Director #1 was unable to be reached, but they were unsure.Attempts to contact Registered Nurse #4 Nursing Supervisor on 08/21/2025 at 10:13 AM and 12:22 PM were unsuccessful.During a telephone interview on 08/21/2025 at 11:11 AM, Nurse Practitioner #1 stated they were out of town on 07/31/2025 and was not taking any calls, they did not receive any update on Resident #119 missing a dose of their Levetiracetam on that date. Nurse Practitioner #1 stated they were familiar with Resident #119 and if they had been updated they missed a dose of Levetiracetam, they would have ordered lab work such as a Keppra (Levetiracetam brand name), a complete blood count, a basic metabolic panel (blood test that measures several key substances in the blood), and an absolute neutrophil count (blood test that measures the number of infection-fighting white blood cells in the body), especially since Resident #119 had seizure activity two days prior. During a telephone interview on 08/21/2025 at 3:14 PM, the Medical Records Supervisor from the pharmacy stated the facility last refilled Resident #119s Levetiracetam on 07/07/2025 and it had not been requested again until 08/04/2025. There was no call or request for the medication on 07/31/2025. The Medical Records Supervisor stated the process for reordering medications was that the facility had automatic reorder sheets, they placed the sticker from the card onto that sheet and faxed it over to the pharmacy, there was a 24 hour turn around. If the facility needed an emergency delivery they would call the pharmacy, it would be profiled as urgent and would arrive the same day. Medical Records Supervisor stated if the facility had ordered the medication on 07/31/2025 in the evening, they would have received the medication the same day.10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 08/22/2025, the facility did not maintain a pest- free environment and an effective pest control program. Specifically, there was of evidence of rodents (dead rodents, rodent droppings) and complaints of rodent sightings in resident rooms. The findings are:The policy and procedure titled Pest Control, revised 11/2024, documented pests can present significant health risks, including the spread of disease, contamination of supplies, and deterioration of hospital infrastructure. The Environmental Services Department is responsible for daily cleaning and maintenance of facilities to minimize conditions conducive to pest infestations. Facilities Management will ensure the physical infrastructure is secure and free of entry points for pests. Food Service will implement sanitation and food handling procedures to prevent pest attraction and contamination in food storage, preparation, and service areas. When an infestation is suspected or confirmed, immediate measures will be taken to address the situation. This may involve the use of pest control specialists, who will assess the infestation and recommend appropriate actions. Review of Pest Sighting Log from 07/07/2025-08/22/2025 provided by the Director of Environmental Services documented pest concerns of mice or a mouse, with vague description of specific location of concern and action taken. On 7/7/25 removed eight (8) dead mice from dietary; 7/8/25 removed mouse from dietary office; 7/10 and 7/11 caught mouse removed, new trap; 8/4 inspected mouse citing in dietary; and 8/22 removed dead mouse, replaced trap in room [ROOM NUMBER] nursing home.Review of Pest Company Service Inspection Reports 07/02/2025 through 08/18/2025 completed by Licensed Exterminator documented: -07/14/2025 one (1) catch in resident room [ROOM NUMBER] that was disposed of.-08/13/2025 one (1) catch was found in resident room [ROOM NUMBER].During the Resident Council Meeting on 08/19/2025 at 2:36 PM, Resident #8 stated that they had seen a mouse a couple of nights ago (over the weekend), and their family member brought in a plug-in device to distract the mice. Observations and interviews on the first floor were as follows: -08/18/2025 at 10:45 AM, revealed a black plastic enclosed box trapper pest monitor on floor next to air conditioning/heat unit under window inside resident room [ROOM NUMBER]. Dry rodent droppings and dust was noted along the outside wall. The resident residing in the room stated a few months ago they had mice in their room and that mice were gross, and they did not want them in their room.-08/18/2025 at 11:45 AM, Resident #45 stated they had seen two (2) mice, one (1) early that morning and one (1) late last night in their room. They stated they saw the mice run across the floor from their closet, and one (1) of them went behind a bag positioned on the floor next to their dresser. Rodent droppings were observed along outside wall in room, and on floor behind the headboard of the bed. A black plastic enclosed box trapper pest monitor was present in room under the window. -08/20/2025 at 9:15 AM, Resident #45 stated they had not seen any mice since 08/18/2025 in their room. They stated maintenance has been to their room, pulled the closet out to check for holes in the wall and that occasionally someone will come into their room to check the bait box. -08/21/2025 at 8:49 AM and 08/22/2024 at 8:25 AM, revealed four (4) black trays with a clear substance were noted in resident room [ROOM NUMBER], three (3) along the walls and one (1) in front of the closet. The resident in the room stated a family member placed the mice traps down on the evening of 08/20/2025 because they complained to them about seeing mice and droppings in their room. The resident stated mice were nasty and it was not homelike and that they should not have to live with mice. During an interview on 08/21/2025 at 4:42 PM, Certified Nurse Aide #11 stated about two (2) weeks ago while providing care in resident room [ROOM NUMBER] during the night shift they saw a mouse run towards the door. They stated they reported the sighting to Registered Nurse #3. During an interview on 08/21/2025 at 4:49 PM, Licensed Practical Nurse #8 stated they have not observed any mice but had heard rumors from staff about mice. If they observed any mice they would call the supervisor immediately. They stated it was an infection control concern to have mice in the facility, was unsanitary and they would not want mice in their home.-08/22/2025 at 8:34 AM, revealed a white cardboard trap between the wall and the side of the closet in resident room [ROOM NUMBER] with a dead mouse present inside of it. -08/22/2025 at 9:23 AM, Registered Nurse #3 stated they were notified of mouse activity on the first floor in room [ROOM NUMBER] or 1008 by a Certified Nurse Aide on the night shift of 08/13/2025-08/14/2025. They stated they did not observe the mouse and notified the Director of Nursing and left a voicemail for the Director of Environmental Services regarding the sighting. Registered Nurse #3 stated there should not be mice in resident rooms due to infection control, mice carry diseases, and it is unsanitary. Registered Nurse #3 observed the dead mouse in resident room [ROOM NUMBER] and stated they would notify the Director of Environmental Services to remove and replace the trap. Review of first (1) floor pest logbook documented on 7/10 in hallway near resident room [ROOM NUMBER], ran to resident room [ROOM NUMBER] or #1037; 7/27/25 at 10:30 a mouse ran out of the bathroom went behind door; 8/14/25 mouse droppings on windowsill in activities room; and 8/21/25 6 PM, mouse ran out bathroom over my shoe. Observations and interviews on the second floor were as follows:-8/20/25 at 11:45 AM revealed a dead mouse was inside a black plastic enclosed box ( trapper pest monitor) inside resident room [ROOM NUMBER], which was occupied. At the time of the observation, the resident stated the last time they saw a rodent was about two to three weeks ago and it was in the hallway near their room. Review of second (2) floor pest logbook documented: 7/11/25 mice in resident room [ROOM NUMBER]; 7/14/25 mouse in resident room [ROOM NUMBER] ran across the floor; 7/20/25 resident saw mice running in to their room; 8/10/25 resident in room [ROOM NUMBER] saw mouse running down hallway; 8/11/25 resident in room [ROOM NUMBER] saw a mouse run across their floor; 8/12 9:30 PM resident in room [ROOM NUMBER] saw a mouse in their room, the mouse came out of wardrobe closet headed toward the door; 8/17 resident in room [ROOM NUMBER] saw mouse in their bathroom.Observations and interviews on the third floor were as follows: -8/20/25 at 12:18 PM revealed a dead mouse inside a black plastic enclosed box ( trapper pest monitor) inside resident room [ROOM NUMBER]. -8/21/25 at 1:40 PM, [NAME] #1 stated there was an approximate three inch wide by two-inch-high piece of vinyl cove base glued to the wall to the right of the door inside resident room [ROOM NUMBER]. At the time of the observation, [NAME] #1 stated they did not personally glue the piece of cove base to the wall, but it appeared as if it was a temporary fix and they would need to schedule a time to return to the room and do complete drywall repair to several areas in this room, including the area behind the resident bed and to the right of the door. During an interview on 8/21/25 at 4:55 PM, Licensed Practical Nurse #9 stated there was a rodent sighting in the high side hallway (north hallway) about one or two weeks ago. They stated they did not personally add it to the exterminator's communication notebook at the Nurses' Station, but there were multiple staff members present at the time of the sighting. During an interview on 08/22/2025 at 8:43 AM, Certified Nurse Aide #9 stated there have been resident complaints of mice in the facility, most recent was on 08/16/2025 while working on the third floor. They stated mice should not be in the resident's home. During an interview on 8/22/25 at 9:59 AM, Housekeeping Staff #1 stated they have seen mice a few times in the facility and residents have complained to them. They inform their supervisor, and the supervisor put mice traps in the resident's room. They stated it was hard to control the mice because the residents were always eating in their rooms and leaving droppings that attract mice. During an interview on 8/22/25 at 10:44 AM, the Licensed Exterminator stated they had just completed an inspection in resident room [ROOM NUMBER]. They stated they found an open sugar packet and a jelly packet on the floor under the resident's bed with mice droppings beside it. They stated some resident's family members brought in plug in devices that send off a scent to keep the mice away but felt they did not work. They stated they cannot use rodenticide in the interior of the building. During an interview on 8/22/25 at 10:48 AM, Resident #8 stated they used to have a parade of mice and now they only see one or two occasionally. Review of third (3) floor pest logbook documented on 7/12/25 mice in resident room [ROOM NUMBER]; 7/17 mouse in resident room [ROOM NUMBER]; 7/24 two (2) mice in resident room [ROOM NUMBER]; 8/2 ceiling tile in hallway near resident room [ROOM NUMBER] moved out of place and heard scrambling footsteps in ceiling; 8/6 mouse in resident room [ROOM NUMBER]; 8/19 mouse in resident room [ROOM NUMBER] in bathroom; 8/21/25 at 3:50 AM mouse in resident bathroom room [ROOM NUMBER] and ran under recliner; 8/21/25 resident in room [ROOM NUMBER] stated they saw a rat. During an interview on 8/20/25 at 3:15 PM, the Licensed Exterminator stated they were on-site at the facility three times per week. They stated they personally checked the containerized traps inside each resident room during the last week of each month and disposed of any catches. The Licensed Exterminator stated there had been progress with this issue and the Administrator and Director of Nursing were responsive to their requests and concerns, but there was still an outstanding issue in resident room [ROOM NUMBER]. They stated they informed the facility of a breakthrough hole in the wall of resident room [ROOM NUMBER] and maintenance staff placed a temporary patch over it, but they were advised a more permanent fix was needed. During an interview on 08/22/2025 at 9:41 AM, the Director of Environmental Services stated they oversaw pest control for the facility. They stated environmental staff, housekeeping, try to monitor mouse traps as much as possible and report finding to them. They stated the exterminator, with the pest control company, comes to the facility three (3) times per week, reviews pest logbooks on each floor, checks mouse traps and addresses concerns documented in the logbooks. They stated resident rooms have cardboard traps that were started with first by the exterminator and then in addition the black trapper pest monitor were added to resident rooms to catch mice. They stated it was important to maintain pest control for resident, staff safety because mice carried diseases and was not homelike. Additionally, the Director of Environmental Services stated ninety (90) percent of pest issues had been addressed since June/July, except for exterior issues, such as exterior doors not closing flush, exterior doors with opening at bottom, and holes in walls. During an interview on 08/22/2025 at 10:40 AM, the Administrator stated rodents were an ongoing, standing issue that has significantly improved. They stated the exterminator was there three (3) days a week, containers had been provided to the residents for food, issues have been discussed with environmental services and rodent traps were in place. They stated they do not know what else they can do. During an interview on 08/22/2025 at 11:30 AM, the Director of Facilities stated they have nothing to do with pest control. During an interview on 08/22/2025 at 12:35 PM, the Director of Nursing #1 stated mice should not be present in resident rooms; it was a sanitary issue having rodents in the facility as they can carry diseases. During an interview on 08/22/2025 at 1:15 PM, Social Worker #1 stated they were aware there was a problem with mice in the facility. They had no residents complain, but family members had complained that it was gross. They did not have any formal grievances regarding the mice, it was strictly verbal complaints. Social Worker #1 stated that rodents in the facility had a negative effect on the residents' quality of life. 10NYCRR 415.29 (j)(5)

Based on observation, interview, and record review conducted during a Standard survey completed on 08/22/2025, the facility did not establish and maintain an effective Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections one (1) (Resident #30) of four (4) residents reviewed. Specifically, the resident had a draining Stage 3 pressure ulcer (a full-thickness skin loss that extends into the subcutaneous tissue but does not involve muscle, tendon, or bone) and was not placed on enhanced barrier precautions (infection control strategy designed to the reduce transmission of multidrug resistant organisms in nursing homes, involving staff to wear a gown and gloves during high contact care). Additionally, staff did not wear appropriate personal protective equipment during pressure ulcer care/treatment.The findings are:The policy and procedure titled Infection Prevention, Transmission-Based Precautions, dated 12/14/2024, documented the staff were to use enhanced barrier precautions in addition to standard precautions for residents with chronic wounds during high-contact care activities. The policy documented staff were to wear gloves and gown during high-contact care activities. Review of the State Operational manual dated 4/25/25 documented Enhanced Barrier Precautions are used in conjunction with standard precautions and expands the use of gown and gloves during high contact resident care activities such as wound care (any skin opening requiring a dressing). Wounds generally include wounds, not shorter lasting wounds such as skin tears covered with a Band Aide or similar dressing. Chronic wounds include but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venosus stasis ulcers. Resident #30 had diagnoses of a fractured left fibula (the smaller of the two lower leg bones), and ankle, and diabetes. The Minimum Data Set (a resident assessment tool) dated 05/13/2025, documented Resident #30 was cognitively intact. The assessment documented the resident had moisture associated skin damage (skin damage caused by prolonged exposure to moisture).Review of the Comprehensive Care Plan dated 08/13/2025 documented that Resident #30 was at risk for altered skin integrity related to decreased mobility, diabetes, and morbid obesity, as well as age-related considerations. Interventions included barrier cream to buttocks every shift, weekly skin assessments during bathing/showering, daily skin monitoring during personal care and toileting/incontinence episodes, and consultation with the wound care nurse as needed. The care plan did not include MASD (moisture associated skin damage) or a Stage 3 pressure ulcer. An Initial Wound Evaluation and Management Summary dated 08/18/2025 at 12:39 PM, documented at the request of the referring provider, a thorough wound care assessment and evaluation was performed today by the facility Medical Doctor. Resident #30 presents with a Stage 3 pressure ulcer on their left buttocks. The documented measurements: length 3.9 centimeters by width 0.7 centimeters, by 0.1 centimeters in depth. Surface area 2.73 centimeters with light serous exudate (drainage-a thin watery clear or yellow fluid) with 100 % (percent) granulation tissue (a type of new, temporary tissue that forms in response to an injury or wound). Dressing treatment plan: primary dressing, add a gauze island with border once daily and as needed if saturated, soiled or dislodged, peri wound add house barrier cream and dressing every day and as needed for thirty days. Review of a physician's order on 08/18/2025 at 14:56 (2:56 PM) documented by the Director of Nursing revealed cleanse the left buttock pressure injury-cleanse with normal saline, apply boarder gauze and house barrier ointment to peri wound.During an observation on 08/20/2025 at 9:41 AM, Licensed Practical Nurse #2 and Certified Nursing Aide #1 entered Resident #30's room to complete pressure ulcer care. There was no signage on the resident's door indicating the resident was on enhanced barrier precautions and there was no personal protective equipment readily available. Both staff members entered the resident's room without applying a protective gown. Certified Nursing Aide #1 their washed hands and applied clean gloves, and assisted with turning the resident onto their side. Licensed Practical Nurse #1 washed their hand and applied clean gloves, and removed the soiled dressing from the resident's left buttocks. There was a moderate amount of serous drainage noted on the dressing. Licensed Practical Nurse #1 completed the pressure ulcer treatment as ordered. During an interview on 08/20/2025 at 9:42 AM, Licensed Practical Nurse #1 they did not apply a gown prior to entering Resident #30's room because they believed Resident #30's pressure ulcer was a Stage 2 (open shallow partial-thickness skin injury that involves damage to the epidermis (outer layer of skin) and part of the dermis (middle layer of skin) and enhanced barrier precautions were only required for Stage 3 and higher-pressure ulcers. They stated they did not check the residents medical record prior to completing the treatment but did look at the 24-hour report and there were no new orders for Resident #30 to be placed on enhanced barrier precautions. During an interview on 08/20/2025 at 10:24 AM, Registered Nurse Unit Manager #1, stated there were no new orders documented on the 24-hour report dated 08/18/2025 and the Licensed Practical Nurse on that shift may have failed to complete the reports. They viewed Resident #30's electronic medical record and stated on 08/18/2025, new orders were entered to cleanse left buttock pressure injury with NS (normal saline), pat dry, apply border gauze daily and PRN (as needed), and to apply A&D to the peri-wound (around the wound). They stated they were not certain if Resident #30 should be on enhanced barrier precautions but believed any chronic wound should qualify. During an interview on 08/20/2025 at 2:54 PM, Registered Nurse Educator #3 stated residents should be placed on enhanced barrier precautions if they have pressure ulcers that were a Stage 2 and higher; or required a dressing. They stated this was important because it would protect residents and staff from cross contamination and decrease infection risks. During an interview on 8/20/2025 at 3:02 PM, the Director of Nursing stated only chronic wounds, such as Stage 3, generally require enhanced barrier precautions, but acute or moisture associated skin damage-related wounds may differ. They stated the wound doctor documented that it was an acute Stage 3 wound, so they did not consider this to be a chronic wound. They stated they put the new orders in the system for wound care on 08/18/2025 and believed enhanced barrier precautions were not necessary for an acute wound. During an interview on 08/22/2025 at 1:03 PM, Licensed Practical Nurse #2 stated the wound care doctor informed them Resident #30's moisture associated skin damage on the left buttocks had now been confirmed to be a Stage 3 pressure ulcer. They stated that a Stage 3 pressure ulcer required a resident to be placed on enhanced barrier precautions, but no one had instructed them to do so. They also stated they did not document on 24-hour report because they assumed the Director of Nursing would process the medical doctors' notes/orders. 10 NYCRR 415.19 (a) (1-2).

Based on interview and record review conducted during the Standard survey completed on 08/22/2025, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months for three (3) (Certified Nurse Aides #3, #4, and #5) of five (5) Certified Nurse Aide files reviewed. Specifically, there was no evidence Certified Nurse Aides #3, #4, and #5 who had worked at the facility more than 12 months had performance reviews completed at least once every 12 months. The findings are:The facility policy titled Non-Management Employee Performance Evaluation Program with an effective date of 11/78 and a revision date of 12/24 documented the purpose of the program was to improve work performance of individual employees, recognize and correct work deficiencies, and identify individual training and education needs.Review of Certified Nurse Aide #3's employee file revealed they were hired 12/03/2023 and their file contained a 90-day performance evaluation dated 03/05/2024. There was no evidence in the employee file that a performance evaluation had been completed in the last 12 months.Review of Certified Nuse Aide #4's employee file revealed they were hired 03/31/2008 and their file contained a most recent performance evaluation dated 04/30/2023. There was no evidence in the employee file that a performance evaluation had been completed in the last 12 months.Review of Certified Nurse Aide #5's employee file revealed they were hired 11/11/2021 and their file contained a 90-day performance evaluation dated 02/10/2022. There was no evidence in the employee file that a performance evaluation had been completed in the last 12 months.During an interview on 08/21/2025 a 11:07 AM, the Director of Nursing #1 stated they were running behind on completing performance evaluations for all staff and that the Human Resources department usually sends out an email when annual performance evaluations were due to be completed, and they had not received an email for this year. They stated annual performance evaluations were completed for all employees at the same time each year and it was important to give staff feedback on how they were doing and what they need to work on. The Director of Nursing #1 provided a performance evaluation for Certified Nurse Aide #3 that had been signed on 04/15/2024 and a performance evaluation for Certified Nurse Aide #4 that had been signed on 04/27/2024. The Director of Nursing #1 stated they had not sent these performance evaluations to the Human Resources department, yet. During an interview on 08/21/2025 at 3:36 PM, the Administrator stated they were aware that annual performance evaluations were due, and they currently had the annual performance evaluation for their management staff on their desk to be completed. They stated performance evaluations were sent out by the Human Resources department in July. The Administrator stated that Unit Managers would be responsible for completing performance evaluations with Certified Nurse Aides.During an interview on 08/22/2025 at 9:29 AM, the [NAME] President of Human Resources #1 stated they were overseeing Human Resources functions for the Hospital and the Nursing home employees, and they had sent out an email to all department management staff on 5/30/2025 instructing them to complete performance evaluations for all of their staff and return the completed performance evaluations to the Human Resources department by 07/09/2025. They stated that it was the Unit Manager's responsibility to complete performance evaluations for Certified Nurse Aides. The [NAME] President of Human Resources #1 stated they had not sent out any reminders about performance evaluations, yet and did not know if any or how many had been returned to the Human Resources Department. They were unsure who the Unit Managers were at the time the email was sent out. The email had been sent to a list titled Department Management List.During an interview on 08/22/2025 at 10:30 AM, Registered Nurse #2 Unit Manager stated they had been the Unit Manager for Unit 3 since the beginning of July 2025 and previously were a part time evening supervisor. They knew that Certified Nurse Aides received performance evaluations annually but stated no one had gone over this process with them.During an interview on 08/22/2025 at 10:42 AM, Registered Nurse #1 Unit Manager stated they had been the Unit Manager for Unit 2 since March 2025 and did not remember receiving an email to complete performance evaluations with the certified nurse aides on their unit and had not been informed of the process.During an interview on 08/22/2025 at 10:54 AM, Registered Nurse #3 Interim Unit Manager 1/Nurse Educator stated they had been filling in for the Unit 1 Unit Manager since June. They checked their emails and had not received an email to complete performance evaluations with their staff. They stated they had not been asked to complete any performance evaluations.During an interview on 08/22/2025 at 11:50 AM, the Payroll/HR Clerk #1 stated they maintained employee files and received performance evaluations from the Director of Nursing, once they were reviewed and signed by all parties. They did not have employee evaluations dated within the last 12 months for the above Certified Nurse Aide (#3, #4, and #5) employee files.10NYCRR 415.26 (d)(7)

Based on observation, interviews and record review conducted during the Standard survey completed on 08/22/2025, the facility did not ensure correct installation, use, and maintenance of bed rails including assessing the resident for risk of entrapment for one (1) (Resident #12) of one (1) resident reviewed. Specifically, Resident #12's bed cane bedrail was loose, not secured to the bedframe, and there was no documentation of routine inspections. In addition, there was no care plan developed for use of the bed cane. The finding is:The policy titled Mobility Assist Rails or other Assist Devices revised 06/22/2023, documented therapy screens each resident to determine bed mobility and what, if any, mobility assist device is warranted. The Comprehensive Care Plan and Closet Care Plan will indicate what mobility assist devices are to be used. A new Evaluation for Mobility Assist Rail/Device Use is to be initiated with each therapy screen if use remains warranted. Nursing Supervisor is to be contacted if mobility assist devices are not available on the unit, and maintenance is to be contacted with concerns regarding application.Review of the Medical Equipment Management Plan reviewed 05/25, provided by the Director of Nursing, documented to ensure that hospital clinical equipment is in optimal and safe condition, Clinical Engineering Department is responsible for testing, repair and schedule maintenance of all equipment that will be used in the patient care area. All patient care equipment shall be included in the master device inventory database with safety and preventative maintenance schedules. Hospital beds are supported and tested by the Facilities Management Department.The bed User-Service Manual dated 2015, provided by Senior Mechanic on 8/22/25, documented warning: possible injury or death. Gap between assist device must be small enough or large enough to prevent resident from getting their head or neck caught in this location (see specific Assist Device Installation Instructions for more information). Entrapment zones involve the relationship of components often assembled by the healthcare facility. Therefore, compliance is the responsibility of the facility. Preventative Maintenance, follow all warnings and cautions in the User Manual. A thorough inspection should be conducted monthly.Resident #12 had diagnoses that included obesity, osteoarthritis, and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 05/25/2025 documented Resident #12 was understood, understands, and was cognitively intact. Partial/moderate assistance was needed with rolling left and right, sit to lying, and lying to sitting on side of bed.Comprehensive Plan of Care dated 5/20/25 documented Resident #12 required assist with transfers and activities of daily living due to decreased strength, endurance and peripheral edema. Approaches included bed mobility extensive assist of one (1).An undated approach, handwritten documented a bed cane to the right side of the bed.Review of Closet Care Plan dated 06/02/2025 on 08/20/2025 at 10:41 AM, documented for bed mobility the resident was an extensive assist of one (1) and there was an undated, handwritten entry that documented a bed cane to the right side. Review of the Active Order Profile documented an active order dated 3/21/2025 for a bed cane to the right side of bed for turning and position.The Evaluation for Enabler Use dated 03/20/2025, documented Resident #12 had a right-side enabler/bed cane on their bed, a physician's order was obtained, and care plan was updated. It was documented that Resident #12 used the bed cane for turning and positioning self.The Evaluation for Mobility Rail/Assist Device dated 05/23/2025, documented Physical Therapist #1 recommended a right mobility rail for Resident #12. A physician order, device on bed and care plan were documented as completed on 05/23/2025 and signed by interdisciplinary team members. There was no documented evidence of an assessment for entrapment included in the evaluation. During an observation and interview on 08/18/2025 at 10:45 AM and 8/19/2025 at 9:57 AM, an upside down U shaped black bedrail was located on the right side of Resident #12's bed. The bedrail moved very easily when grabbed, sliding out from under the mattress and was not secured to the bedframe. Resident #12 was sitting in their recliner during these times and stated they needed the bedrail to assist them with positioning in bed and that the bedrail belonged to them. Review of Resident #12's Closet Care Plan dated 6/2/2025 that was hanging on their bathroom door documented for bed mobility the resident required extensive assist and did not document they used a bedrail.During an observation and interview on 08/20/2025 at 9:09 AM, Resident #12 was in bed with the head of bed elevated. Bedrail portion towards head of bed pulled out from under mattress while the resident was in bed with very little effort. Resident #12 stated It is loose. It needs to be put under the mattress more. Resident #12 stated their family member brought the bedrail in for them and they could not recall if their family member or a staff member applied it to their bed. They stated they have had the bedrail for about one (1) year. During an observation and interview on 08/20/2025 at 9:41 AM, Certified Nurse Aide #8 stated assistive devices were indicated on resident care plans. Certified Nurse Aide #8 stated they did not see the use of a bedrail indicated on Resident #12's Closet Care Plan hanging on bathroom door. Certified Nurse Aide #8 stated they would be responsible to report safety concerns related to bedrail use, or if a resident no longer utilized the bedrail. They stated maintenance would be responsible for installing and checking the bedrails on the beds. Certified Nurse Aide #8 observed the bedrail on the right side of the bed and stated the bedrail was not secured to the bed. Upon pulling on the bedrail, it slid out from under the mattress. Certified Nurse Aide #8 stated the bedrail was not safe and if Resident #12 pulled on the bedrail they could fall.During an observation and interview on 08/20/2025 at 11:07 AM, Senior Mechanic and the Director of Nursing were observed removing the upside down U shaped bedrail from Resident #12's bed. Senior Mechanic stated they had never seen a bedrail like that before. The Director of Nursing stated the bedrail in use was not sturdy and was not provided by the facility. The Senior Mechanic and the Director of Nursing were then observed to apply a facility provided bed cane bed rail to Resident #12's bed. During an interview on 08/20/2025 at 11:21 AM, Senior Mechanic stated they were responsible to apply and remove bedrails from resident beds in the facility. They stated once they were applied, they did not generally check the bedrails again, unless they were notified of a concern. They stated they were not aware of any concerns regarding Resident #12's bedrail prior to that day. They stated to their knowledge there was no routine or preventative maintenance performed on the resident's beds or bedrails. They stated there could be a concern for safety, injury, if bedrails were not applied or maintained correctly to the resident or anyone for that matter. During an interview on 08/20/2025 at 11:33 AM, Registered Nurse #3 stated they were notified that morning by Certified Nurse Aide #8 that Resident #12's bedrail was loose, and they reported it to the Director of Nursing. Registered Nurse #3 stated they knew Resident #12 was supposed to have a bedrail for assisting them with turning and positioning. They stated they had seen bed canes bedrails before but did not recall the particular bed cane that was on Resident #12's bed. They stated therapy completed bed mobility evaluations and made the recommendation for the use of bedrails. They stated maintenance was responsible for applying bedrails to resident's beds. Registered Nurse #3 stated it was important for bedrails to be secured to the bed for resident safety and did not want anyone to fall out of the bed.During an interview on 8/22/25 at 8:58 AM, Physical Therapist #1 stated therapy was responsible for evaluating the need for a bedrail on a resident's bed. They stated they assessed residents' ability to use bedrails safely and if bedrail use was appropriate. They stated they evaluated Resident #12 and completed an assessment form a couple of weeks ago. They stated they physically assessed Resident #12 while in bed and did not recall the type of bedrail on the bed or what it looked like. Physical Therapist #1 stated nursing was responsible for updating the care plan for the use of a bedrail.During an interview on 8/22/25 at 11:30 AM, the Director of Facilities stated maintenance was responsible to complete work orders pertaining to beds. They stated there was no routine or preventative maintenance performed on resident beds. When maintenance gets notified of an issue, they fix the issue or pull the equipment out of service, so it was safe. The Director of Facilities stated they had not looked at any bed manuals and did not know if they even had manuals for all the beds used in the facility. They stated it would not be a bad idea to see what the bed manuals recommended for routine maintenance. The Director of Facilities stated they were not aware of any process for checking for entrapment with the use of bedrails. They stated administration provided guidance on entrapment and purchased bedrails that were compatible with the bed frames.During an interview on 08/22/2025 at 12:35 PM, the Director of Nursing stated when a bedrail was recommended by therapy, a work order was placed to maintenance to install. They stated Resident #12 had a facility provided bedrail on the bed, but it was swapped out by a family member, per therapy. They stated per therapy recommendations Resident #12 had a bedrail initiated 03/2025 and the bedrail should have been reviewed during care plan meetings to ensure it was reflected on their care plan. They stated it was important for the bedrail to be part of a care plan, so staff knew about it. The Director of Nursing stated the maintenance department was responsible for routine, preventative maintenance on the beds used in the facility. The Director of Nursing stated they did not have any evidence that entrapment measurements were completed prior to 08/20/2025. They stated they were revamping the process for measuring for entrapment because there was a failure in the process and a risk for injury with the use of bedrails. They stated they had updated the Closet Care Plan and the Comprehensive Plan of Care when they were notified the bed cane was not present because it needed to be fixed (on 08/20/2025).During an interview on 08/22/2025 at 1:15 PM, the Administrator stated ideally, they would not like to see bedrails utilized in the facility. They stated therapy should be evaluating use of bedrails in person in the resident's rooms. They stated staff as a team were responsible for educating residents, families on bedrail use and review bedrail use during change in conditions, Minimum Data Set review, referral and care plan review. They stated they were not aware of any routine maintenance to the beds and bedrails. They stated nursing and therapy were responsible for evaluating for hazards associated with bedrail use.10 NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 08/22/2025, the facility did not ensure that each resident received proper treatment to maintain vision for one (1) (Resident #30) of one (1) resident reviewed. Specifically, Resident #30's optometrist appointment on 06/06/2025 required an outside consult visit that was not scheduled. Additionally, Resident #30 complained that they were unable to see well with their current eyeglass prescription.The finding is:The policy titled Dental, Hearing, and Vision Evaluations, dated 03/2011, documented that the facility will assure residents can function at their highest practical level of oral health, vision, and hearing. The policy states to assess functional status on admission, quarterly, as per the MDS schedule, and when concerns are reported. If a resident or surrogate decision-maker agrees to a consult/evaluation, the facility is to arrange for the consult as soon as possible.Resident #30 had diagnoses including unspecified fracture of the shaft of the left fibula (the smaller of the two lower leg bones), fracture of the left ankle; and diabetes with diabetic neuropathy (nerve damage causing numbness or weakness). The Minimum Data Set, (a resident assessment tool) dated 05/13/2025 documented Resident #30 was cognitively intact, could understand others, and could be understood by others. Resident #30's vision was adequate with corrective lenses. They had impairment of one lower extremity and utilized a wheelchair for mobility.Review of the Comprehensive Care Plan dated 08/13/2025 documented that Resident #30 wore glasses, had impaired vision, but could see large print. Interventions included but were not limited to assessing and reporting changes that may indicate a change in vision and arranging eye consults as per policy/procedure and as needed.Review of the Closest Care Plan dated 08/13/2025 documented that Resident #30 wore prescription glasses.Review of the Eye Consult Form dated 06/06/2025 documented that Resident #30 was seen in the facility on 06/06/2025 and was to have a referral sent to an outside optometrist to determine if a new prescription would improve their vision or if cataract surgery was indicated. The form was signed by the Unit 2 Manager, Registered Nurse #1.During an observation and interview on 08/19/2025 at 12:01 PM, Resident #30 stated they told a Certified Nursing Aide that their glasses no longer helped them see but could not remember the aide's name. They also stated they informed a family member, who notified staff. Resident #30 further stated they had seen an eye doctor a couple of months prior and were supposed to see another one, but the appointment was never scheduled. Resident #30 put their glasses on, picked up an activity program, and said they could not read the small print.During an interview on 08/20/2025 at 11:21 AM, a PACE (Program of All-Inclusive Care for the Elderly) Case Manager #1 stated there were no records indicating that Resident #30 required an outside consult. They stated it was the facility's responsibility to notify them if an outside appointment was needed. They stated the facility should fax physicians' recommendations and consult referrals to them, and they would schedule the appointments, notify the facility, and arrange transportation. They confirmed there were no notifications in their system regarding an outside eye doctor appointment for Resident #30.During an interview on 08/20/2025 at 2:54 PM, the nurse educator, Registered Nurse #3, stated that all follow-up appointments were to be made by the Unit Manager. They stated Resident #30's appointments were scheduled through their case manager, but it was the Unit 2 Manager Registered Nurse #1's responsibility to contact Resident #30's case manager at the Program of All Care for the Elderly to inform them that an outside referral with an Ophthalmologist was needed.During an interview on 08/22/2025 at 9:30 AM, Resident #30's family member stated they had informed staff that Resident #30 needed an outside consult with an optometrist. They reported that someone contacted them about this but were unsure who. They also stated that during a visit on the following day, they told an aide or a nurse their loved one needed a referral from the 06/06/2025 eye doctor appointment, and it was staff's responsibility to follow up with their case manager from the Program of All Care for the Elderly.During an interview on 08/22/2025 at 11:22 AM, Unit 2 Manager Registered Nurse #1, stated that they knew the Program of All Care for the Elderly scheduled outside consult appointments for Resident #30 and it was their responsibility to contact the case manager. They stated they were not aware this was their responsibility in June 2025 because they were never informed. They stated they contacted a family member at the end of June and thought the family member would follow up with the case manager. They confirmed that they had not yet contacted the Program of All Care for the Elderly regarding Resident #30's optometrist appointment.During an interview on 08/22/2025 at 3:15 PM, the Director of Nursing stated they expected staff to provide them with any referrals for an outside consult. They stated Unit 2 Manager Registered Nurse #1 was responsible to follow up with the resident's case manager at Program of All Care for the Elderly so they could make the optometrist appointment for Resident #30. They stated the case manager would follow up and arrange with the resident, the facility, and transportation. They stated after appointments were followed up on, Unit Managers would bring them referrals to scan.NYCRR 415.11(c)(3)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Complaint Investigation (Complaint #NY00370870), the facility did not maintain an effective pest control program for two (second and third floors) of four resident use floors and the Main Kitchen. Issues included observations of evidence of rodents (dead rodents and rodent droppings) and complaints of rodent sightings in resident rooms. Additionally, on the exterior of the building, used kitchen grease was stored in a manner that had the potential to attract rodents. Residents A, B, C, D, E, F, G, H, I, J, and K were involved.
The findings are:
The policy and procedure titled Pest Control, effective 11/2024, documented pests can present significant health risks, including the spread of disease, contamination of supplies, and deterioration of hospital infrastructure. The Environmental Services Department is responsible for daily cleaning and maintenance of facilities to minimize conditions conducive to pest infestations. Facilities Management will ensure the physical infrastructure is secure and free of entry points for pests. Food Service will implement sanitation and food handling procedures to prevent pest attraction and contamination in food storage, preparation, and service areas. When an infestation is suspected or confirmed, immediate measures will be taken to address the situation. This may involve the use of pest control specialists, who will assess the infestation and recommend appropriate actions.
1a. Observations and interviews on the third floor were as follows:
During an interview on 5/6/25 at 8:20 AM, Resident A stated they saw rodents all of the time in their room and in the hallway. They stated, I see them every day, everywhere. They stated they had observed rodents and rodent droppings inside the dining room, where they ate their meals. At this time, approximately ten rodent droppings were observed in Resident A's room inside their tall wardrobe.
During an interview on 5/6/25 at 8:28 AM, Resident B stated they had two small mice in their room at different times and the last one was observed about one and a half weeks ago. Resident B stated a male Certified Nurse Aide tried to get it, but they could not. The first one was seen by a nurse under their bed. They stated, I can't sleep at night thinking its crawling around. At this time, a cardboard box was observed behind the dresser in Resident B's room. The box contained two snap traps and one of the snap traps had a dead mouse in it.
During an interview on 5/6/25 at 8:32 AM, Licensed Practical Nurse #1 stated the facility was battling mice and an exterminator came in regularly. They stated there had been no resident complaints recently.
On 5/6/25 at 11:37 AM, Licensed Practical Nurse #1 was shown the dead mouse in Resident B's room. They stated they needed to call Housekeeping to get someone to pick it up. They stated they were not aware of the dead mouse in this room, and no one should live with mice in their room, this needed to be taken care of right away.
Observation in the third floor Dining Room on 5/6/25 at 8:35 AM revealed rodent droppings along the wall under the window.
During an interview on 5/6/25 at 8:43 AM, Housekeeper #1 stated they had seen rodent droppings multiple times in resident rooms [ROOM NUMBERS]. They stated when they saw droppings, they always told their supervisor. Some residents stored food in containers, but the containers weren't always covered, and that could be a problem. Housekeeper #1 stated they swept and mopped the floors of each resident room in their assignment daily.
During an interview on 5/6/25 at 8:44 AM, Housekeeping Supervisor #1 stated the radiators in each room in the nursing home were re-caulked and steel wool was used to seal around them. They stated this was done by the exterminating company to eliminate rodent entry points. They stated the exterminator visited the facility every Monday, Wednesday, and Friday and nurses tried to educate residents to not keep open food in their rooms.
During an interview on 5/6/25 at 11:19 AM, Resident C stated they had seen rodents all over their room. They stated they last saw a mouse yesterday and the mice did not bother them. At this time, rodent droppings were observed in the bathroom behind the metal garbage can in Resident C's room. Also, rodent droppings were observed on the floor to the left of the tall wardrobe in Resident C's room.
Observation on 5/6/25 at 11:26 AM revealed rodent droppings were observed around the black plastic containerized rodent trap under the window in Resident room [ROOM NUMBER].
Observation on 5/6/25 at 11:30 AM revealed the lower cover was off the radiator in Resident room [ROOM NUMBER] and there were rodent droppings on the floor under the radiator, and the area was very dusty.
During an interview on 5/6/25 at 11:35 AM, Certified Nurse Aide #1 stated they saw a couple of rodents when they first started working at this facility around January 2025, but not much since then. They stated they had just seen the ones stuck in traps, maybe two. Certified Nurse Aide #1 stated residents would tell them if there was something that they were seeing, and the last time a resident said something to them was about a month ago or longer.
During an interview on 5/6/25 at 11:44 AM, Resident D's spouse stated they had not seen a rodent in Resident D's room in a few weeks. They stated their spouse did get all excited about the rodents, but it did not bother them personally. At this time, rodent droppings were observed on the floor behind the dresser in Resident D's room.
During an interview on 5/6/25 at 12:00 PM, Resident E stated they had caught two mice in their room in food containers a couple of months ago. The resident stated they were blind. At this time, rodent droppings were observed behind the dresser and droppings were behind the nightstand in Resident E's room. In the top drawer of nightstand, there were rodent droppings. Also, the nightstand had two open shelves, and each had rodent droppings. Resident E had three plastic food containers with lids, which were loosely sitting on the containers, and rodent droppings were on the floor around the plastic food containers, which were to the left of the resident's chair. Additional observation revealed there was a black plastic containerized rodent trap on the floor near the window. There were droppings on floor around the trap and two dead mice were in the trap. Resident E stated, Rodents do not scare me, but it was a pain in the neck if they get into my food, a couple were in my cookies, and I had to throw my cookies away. Resident E stated they could not recall the exact time of that incident. On 5/6/25 at 3:27 PM, Resident E added that it was a while ago that a mouse crawled into their cookie container, and they heard the mouse rustling around the wrapper in the container, which was how they knew it was trapped in there. They stated they were alone in their room when it occurred, but everybody knew about it and staff took pictures of it. They stated they were happy it was caught.
On 5/6/25 at 12:10 PM, Licensed Practical Nurse #1 was shown the dead mice and droppings in Resident E's room. Licensed Practical Nurse #1 stated the nightstand drawer needed to be cleaned out and the trap needed to be emptied. They stated the mice and droppings could be old, but that would not be a good thing either. They stated if the droppings were old, that meant they should have been cleaned up by now.
Observation on 5/6/25 at 1:31 PM revealed rodent droppings were on the floor between the wall and the brown leather chair inside Resident room [ROOM NUMBER].
During an interview on 5/6/25 at 1:34 PM, a family member of Resident F stated they had noted improvement in the rodent situation, with no sightings for a long time, but around a month ago, the rodents popped up again. They stated the rodents did not scare Resident F, but Resident F will report when they had seen one. The family member stated they personally supplied Resident F's room with two snap traps and one glue board trap. They stated they caught one rodent on their glue board trap about one month ago. At this time, rodent droppings were observed on the floor to the right of the radiator, near a small box of rodent bait.
Review of the third-floor pest control logbook located at the Nurses' Station revealed entries stated there were rodent sightings on 4/25/25 in Resident room [ROOM NUMBER] at 11:00 PM, in Resident room [ROOM NUMBER], and on 5/6/25 in Resident room [ROOM NUMBER] at 5:00 AM.
1b. Observations and interviews on the second floor were as follows:
During an interview on 5/6/25 at 8:50 AM, Resident G stated the mice were still around, and they just saw one the other day. It was alive on the top of their dresser.
During an interview on 5/6/25 at 8:58 AM, Licensed Practical Nurse #2 stated they had not seen any rodents recently, which was a great improvement. They stated they last saw a rodent in the second floor Dining Room in December 2024. They stated occasionally, residents would make a complaint about a rodent sighting in their room, and they would enter the information into the logbook that served as communication between the staff and the exterminator.
During an interview on 5/6/25 at 9:00 AM, Resident H stated it had been a few weeks since they last saw a rodent in their room. At this time, a few dusty rodent droppings were observed on a shelf behind several empty soda cans.
During an interview on 5/6/25 at 9:10 AM, Resident I stated they last saw a rodent in their room a couple of weeks ago, and it was on their chair and pillow.
During an interview on 5/6/25 at 9:03 AM, Resident J stated they saw a large rodent in their room about three weeks ago and a man came in and stated they would take care of it. Resident J also stated it was unnerving to witness a rodent in their room.
During an interview on 5/6/25 at 9:28 AM, Certified Nurse Aide #2 stated the last time they saw a rodent in the building was three weeks ago. They stated when they worked nights, they would see them in the hallways, but it had improved in the last couple of weeks.
During an interview on 5/6/25 at 1:25 PM, a family member of Resident K stated they last saw rodent droppings in Resident K's room on 4/27/25 and the last time they saw a rodent in the room was about one month ago. The family member stated someone blocked holes around the radiator in Resident K's room a few days ago. They stated during football season, they brought in their own snap trap and caught a mouse in Resident K's room in the trap. At this time, no rodent droppings were observed in Resident K's room.
Review of the second-floor pest control logbook located at the Nurses' Station revealed on 5/1/25, two entries stated a mouse was running in Resident room [ROOM NUMBER]. Also in Resident room [ROOM NUMBER], a sighting occurred in the radiator on 4/27/25.
1c. Observations and interviews in the Main Kitchen were as follows:
During an interview on 5/6/25 at 10:10 AM, the Food Service Director stated the rodent situation was much improved, there were still occasional rodent sightings in the kitchen, and an exterminator came three times per week to maintain the traps. They stated deep cleaning behind all racks was done on a weekly basis. The Food Service Director stated all condiments, bread, and soup bowls were stored in the cooler and multiple openings in kitchen walls and ceilings were patched.
Observation in the kitchen on 5/6/25 at 10:15 AM revealed rodent droppings on the floor on the right-side corner of the three-bay sink and droppings on the white painted area where water jugs were stored. Additionally, in the large dry storage room, there was one small pile of droppings behind the closed bin with packaged cookies. In this room, all food was stored in covered plastic bins. No droppings were observed inside the bins, but the two bins had one dropping each on top of their lids. Inside the tray line room revealed rodent droppings on the floor near the side wall with windows and droppings around containerized rodent box #32, which was also close to the windows. Rodent droppings were observed on the floor of the tray line room between the cooler and the handwash sink.
1d. Observations and interviews at the exterior grease storage area were as follows:
Observation on the exterior of the facility on 5/6/25 at 10:30 AM revealed the dumpster for used kitchen grease had a greasy substance that covered about one-quarter of its lid. The substance was heavily streaked down the left vertical wall of the dumpster and appeared lighter on the right vertical wall. At the time of the observation, the Food Service Director stated the grease dumpster and the area around it were thoroughly scraped, degreased, and cleaned last Monday, and it was spotless at that time. The Food Service Director stated facility staff poured used grease into this dumpster around two times per week and an outside contractor pumped the grease out.
1e. Observations and interviews at the loading dock were as follows:
Observation from the inside of the loading dock on 5/6/25 at 10:37 AM revealed there were two garage doors. The door on left had two small areas of daylight on each side at the base, one inch wide each. The door on right had two small areas of daylight at the base, one at the end and one in middle, about one-half of an inch wide each.
During an interview on 5/6/25 at 10:53 AM, the Director of Environmental Services stated the facility identified potential rodent entry points under the radiator covers. The facility had exterminators remove every radiator cover in the nursing home and seal all holes. This was completed around February 2025. The Director of Environmental Services further stated for about six weeks after completion of project, there were no new complaints of rodent sightings. They stated sweeping and mopping all rooms was an everyday task. Housekeepers were able to do a detailed cleaning of five to six additional rooms each day. The Director of Environmental Services stated a detailed cleaning included cleaning all surfaces and moving and cleaning behind all furniture. They stated if any rodent droppings were sighted, they or the Housekeeping Supervisor would be notified, and the housekeeping staff would be assigned to perform a detailed cleaning of that room. Additionally, on 5/6/25 at 1:08 PM, the Director of Environmental Services stated the exterminator provided the black plastic containerized rodent traps that were placed in most rooms throughout the nursing home. They stated the exterminator checked the boxes when there was a sighting or report, but they did not check every box every time they visited the facility. They stated the cardboard boxes with snap traps were provided by the facility, they were used by facility staff if they heard of something, and the exterminator was not there. On 5/6/25 at 2:46 PM, the Director of Environmental Services stated they were not aware that Resident E claimed to have caught a rodent in a cookie container, and they were not aware of any rodent sightings in Resident E's room. They added that the issue was not 100 percent eradicated yet, and the building was old, which could be a contributing factor.
During a telephone interview on 5/6/25 at 3:02 PM, the Administrator stated the exterminator came to the facility three times per week and there had been significant improvement, but the rodent issue was still a work in progress with on-going audits and checks. The Administrator stated exclusion work around every radiator in the nursing home was done and an outside contractor deep cleaned the kitchen over the course of several nights. They stated the exterminator monitored the sighting logbooks at each Nurses' Station and issues identified by the exterminator were forwarded to the Environmental Services or Maintenance departments and were handled promptly, which led to a decrease in sightings. The Administrator stated they had very few resident or staff complaints regarding rodents lately. The age of the building and its geographic location were factors, according to the Administrator. They stated some of the residents who stored food in their rooms were more compliant than others. The facility provided plastic or metal bins for food storage to any resident and the facility kept extras on-hand and would purchase additional bins as needed. The Administrator stated Activities staff reminded residents at Dining Committee meetings about the importance of proper food storage and that containers were available for anyone that wanted one. They stated the grease dumpster was cleaned weekly, and garbage that was stuck on the top of the grease dumpster could contribute to splattering when grease was poured into it.
The Detailed Cleaning Rooms Third Floor Nursing Home report documented Resident A's room was deep cleaned on 5/2/25, Resident B's room was deep cleaned on 4/28/25 and 5/3/25, Resident D's room was deep cleaned on 4/17/25, and Resident E's room was deep cleaned on 4/26/25.
The exterminator's Service Inspection Report dated 5/5/25 documented two catches in Dietary were disposed of, and sanitation conditions continued to be maintained.
The exterminator's Service Inspection Report dated 4/30/25 documented three catches in Dietary were disposed of. rooms [ROOM NUMBERS] had catches.
The exterminator's Service Inspection Report dated 4/28/25 documented four catches in Dietary were disposed of.
The exterminator's Service Inspection Report dated 4/24/25 documented heavy rodent pressure was observed on the exterior of the building. The report documented concerns over doors that were left open and trash outside of the receiving dock.
The exterminator's Service Inspection Report dated 4/23/25 documented one catch in Dietary was disposed of. The report documented that room [ROOM NUMBER] had one catch that was disposed of, and food debris was noted in that room.
10 NYCRR 415.29(j)(5)

Based on observation, interview, and record review completed during a Complaint (#NY00339959) investigation, the facility did not ensure that each resident received adequate treatment and services for a Foley catheter (tube that drains urine) for one (Resident #2) of two residents reviewed for catheter care. Specifically, staff did not keep the urine collection bag below the level of Resident #2's bladder during care and the resident had a history of frequent urinary tract infections.
The finding is:
Review of the policy titled Catheter Care, Urinary obtained from the Med-Pass Nursing Services Policy and Procedure Manual for Long-Term Care dated 2001, provided by the Director of Nursing, revealed staff are required to always position the drainage bag lower than the bladder to prevent urine flowing back into the urinary bladder. The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.
Resident #2 had diagnoses including hydronephrosis (enlargement of the kidney) with obstructive uropathy (obstruction in urinary tract), post right ureteral stent (small flexible tube inserted in kidney duct) placement and urinary tract infection. The Minimum Data Set (a resident assessment tool), dated 11/23/24, documented Resident #2 had moderate cognitive impairment, was usually understood, usually understands, and had an indwelling catheter.
Review of the Comprehensive Care Plan initiated on 12/2/24 revealed Resident #2 had obstructive uropathy and required the use of a foley catheter with directions for catheter care according to established policy and to keep the catheter bag below the resident's bladder.
Review of the current Closet Care Plan (used by staff to guide care) dated 11/14/24 documented Resident #2 under continence had a Foley catheter.
Review of the Operative Report dated 2/4/25 revealed the resident had a cystoscopy (medical procedure to examine the bladder and urethra) for a right ureteral (thin tube that carries urine from kidney to the bladder) exchange and removal of kidney stones in the right ureter. Surgical aftercare remained the use of a Foley catheter and treatment with Levofloxacin (antibiotic medication used to treat infections) 500 mg (milligram) tablets daily.
Review of Medication Orders dated 2/4/25 directed the use of Levofloxacin 500 mg (milligrams) tablet daily for seven days for prophylaxis (measure taken to prevent disease or infection) treatment.
Review of the Physician's Progress note dated 2/6/25 revealed the resident has a history of obstructive uropathy with frequent urinary tract infections and had a cystoscopy, with plans to continue the use of a Foley and for the resident to complete a course of Levofloxacin.
During an observation on 2/10/25 at 11:52 AM, Certified Nurse Aide #1 was at the resident's bedside preparing to provide hands on care. The resident was lying flat in bed with the urine collection bag on the bed mattress. The resident remained lying flat during the bed bath and brief change. The Certified Nurse Aide #1 emptied the urinary collection bag full of clear yellow urine by lifting the bag approximately a foot above the resident's torso; the urine was visibly backflowing towards Resident #2's bladder. Certified Nurse Aide #1 placed the urinary collection bag through the pant leg while dressing the resident in bed and left the urinary collection bag on the mattress with the resident still lying flat in bed at 12:09 PM.
During an interview on 2/10/25 at 12:27 PM, Certified Nurse Aide #1 stated the urine collection bag the resident had after recent surgery several days ago did not reach below the resident's bladder and was reported to nursing staff. Certified Nurse Aide #1 said they always emptied the urine collection bag in the same manner and was aware that the bag is supposed to remain below the resident's bladder to prevent infection.
During an interview on 2/10/25 at 2:20 PM, the Registered Nurse Nurse Manager #1 stated it was unacceptable to empty a urinary catheter bag by raising it above the resident's bladder to prevent infections. The Registered Nurse #1 Nurse Manager also stated when the resident returned from surgery last week, staff had informed them that the urinary catheter bag placed in surgery had shorter tubing. The Registered Nurse Nurse Manager #1 stated they would call the surgeon today to determine how to proceed with this issue.
During a telephone interview on 2/11/25 at 9:39 AM, the Surgeon/Physician stated that staff did not inform them of a problem with Resident #2's urinary catheter bag until 2/10/25 after the surveyor's observation. The Physician/Surgeon stated that it is important to keep the bag below the bladder to decrease risk of infection especially for this resident who was at high risk for urinary tract infections.
During an interview on 2/10/25 at 12:26 PM, the Registered Nurse #3 Infection Control Preventionist stated they were aware that Resident #2 went to surgery last week and was sent back to the facility with a different urine collection bag that was shorter and did not have clips for hanging the bag. Registered Nurse #3 Infection Control Preventionist stated they do not change devices placed by surgery until there is surgical follow up and stated they did not report the problem to anyone else. During the interview an observation of the urinary drainage bag was performed at the resident's bedside with Registered Nurse #3 Infection Control Preventionist who viewed that the bag was able to reach slightly below the resident's bladder and the urinary drainage bag had slits at the top to accommodate clips and/or straps to secure the urinary drainage bag below the resident's bladder.
10 NYCRR 415.12(d)(1)

Based on observation, interview, and record review completed during a Complaint (# NY00339959) investigation, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of three residents reviewed for infection control practices. Specifically, Resident #2 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment during care while emptying a urine drainage bag.
The finding is:
Review of the policy titled Infection Prevention dated 12/2024 revealed procedures for isolation and universal precautions will be placed for residents suspected or confirmed to have a contagious or infectious disease. Masks, gowns and gloves should be used as protective barriers when needed to reduce the risk of exposure of the health care worker's skin or mucous membranes to potentially infectious material. Enhanced Barrier Precautions are used in conjunction with standard precautions and expand the use of personal protective equipment to donning (putting on) of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug-resistant organisms to staff hands and clothing including dressing, bathing/showering, transferring, changing linens, changing briefs, wound care, and contact with a urinary catheter.
Resident #2 had diagnoses including hydronephrosis (enlargement of the kidney) with obstructive uropathy (obstruction in urinary tract), post right ureteral stent (small flexible tube inserted in kidney duct) placement and urinary tract infection. The Minimum Data Set (a resident assessment tool), dated 11/23/24, documented Resident #2 had moderate cognitive impairment, was usually understood, usually understands. Resident #2 required maximal assistance for personal hygiene, was totally dependent on staff for toilet hygiene and dressing, and moderate assistance for bed mobility.
Review of the Comprehensive Care Plan initiated on 12/2/24 revealed Resident #2 required assistance with transfers and activities of daily living due to decreased balance and strength and required Foley catheter care.
Review of the current Closet Care Plan (used by staff to guide care) dated 11/14/24 revealed the resident had a Foley catheter for continence and required extensive to maximal assistance for bathing and extensive assistance for bed mobility.
Review of Physician Orders dated 11/14/24 revealed Foley catheter related to diagnosis of obstructive uropathy, standard precautions.
Review of the Physician's Progress note dated 2/6/25 revealed the resident has a history of obstructive uropathy with frequent urinary tract infections and had a cystoscopy, with plans to continue the use of a Foley and for the resident to complete a course of Levofloxacin (antibiotic medication to treat infections).
During an observation on 2/10/25 at 11:52 AM, a sign for enhanced barrier precautions was posted on Resident #2's door and directed staff to use a mask, gowns, and gloves for hands on care. Certified Nurse Aide #1 was observed at the resident's bedside wearing gloves, but no mask or gowns. Certified Nurse Aide #1 performed a bed bath that included assisting the resident with bed mobility, emptied the urinary collection, changed the resident's clothing, and handled soiled linens while wearing the same pair of gloves; the resident care activities performed were completed at 12:09 PM.
During an interview on 2/10/25 at 12:27 PM, Certified Nurse Aide #1 stated yes, they should have had a gown and mask on in Resident #2's room to prevent infection, they forgot.
During an interview on 2/10/25 at 12:26 PM, Registered Nurse #3 Infection Control Preventionist stated Resident #2 is on enhanced barrier precautions because of the use of the Foley catheter in accordance with the facility's nursing standard of practice. Staff are required to wear a gown, mask, and gloves for residents on enhanced barrier precautions to prevent the spread of infections.
During an interview on 12/10/25 at 1:27 PM, the Director of Nursing stated that the resident is on enhanced barrier precautions for the use of the Foley catheter and staff are required to wear a mask, gown and gloves during hands on care to prevent infections.
10 NYCRR 415.19(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Complaint Investigation (Complaint #NY00351197), the facility did not maintain an effective pest control program for three (First, Second, and Third Floors) of four resident use floors and the Main Kitchen. Issues included observations of evidence of rodents (droppings) and complaints of rodent sightings in resident rooms. Additionally, on the exterior of the building, garbage and used kitchen grease were stored in a manner that had the potential to attract rodents. Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P were involved.
The findings are:
The policy and procedure titled Pest Control, effective 10/1/14, documented efforts will be made to ensure that pests are controlled throughout the facility, including the food service department. Regular inspections will be performed by a pest management professional. The inspector will note situations that are conducive to pest populations and recommend repairs, sealing of pest entry points, clutter reduction, improved sanitation, and monitoring procedures. Repairs will be performed as needed to prevent pest access to buildings or to hiding spaces in walls and equipment. Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests. Additionally, in food service areas, all exterior openings are to be closed tightly, and garbage containers are to be kept clean, in good condition, and tightly covered in all indoor and outdoor areas. Garbage containers will be washed, rinsed, and sanitized regularly.
During a telephone interview on 10/3/24 at 2:45 PM, the Administrator stated there had been an uptick in rodent sightings since late August or early September 2024. They stated the facility recently changed exterminator companies and increased the frequency of exterminating services from weekly to two times per week. The Administrator further stated the facility bought containers for residents' snacks in their rooms, did a thorough cleaning of the dining rooms. The condiments packets from the hutches in the dining rooms were moved to the steel cabinetry in the kitchenettes. Residents who like to keep snacks in their room and who had a heavy amount of belongings were identified and the Environmental Services staff increased terminal cleaning in those resident rooms. The Administrator stated Maintenance staff went around the building patching any identified holes. The Administrator stated there was a walk-through of the Main Kitchen last month, and the Food Service Director made changes to food storage methods and added more frequent deep cleaning at that time. The used kitchen grease outside of the hospital was last cleaned out two weeks ago as well a deep clean of the inside of the Main Kitchen, specifically focused on the stoves and areas with grease build up.
1a. Observations and interviews on the Third Floor were as follows:
During an interview on 11/12/24 at 8:40 AM, Certified Nurse Aide/ Unit Clerk #1 stated they had seen rodents in the hallways on the resident units. They had observed a mouse inside a resident room on the Third Floor, which was now vacant, and had heard residents on the Third Floor complaining about mice. They stated they had seen improvement lately when a new exterminator started coming to the facility.
Observation inside Resident room [ROOM NUMBER] on 11/12/24 at 8:45 AM revealed a black plastic enclosed box and a white cardboard glue trap were present on the floor. There were approximately eight rodent droppings on the floor between the edge of the bed and the corner wall closest to the window, under the resident's cane.
During an interview on 11/12/24 at 8:49 AM, the Licensed Exterminator stated they visited the facility two times per week. They stated the black plastic enclosed boxes and the white cardboard glue traps were set and monitored by their company. The Licensed Exterminator stated the black plastic enclosed boxes, referred to as containerized traps, were locked and had a sheet of glue paper inside. There was a containerized trap in every resident bedroom in the nursing home. They stated they did not use poison indoors, but did use bait boxes that contained poison on the exterior of the property. At this time, the Licensed Exterminator looked at the rodent droppings on the floor inside Resident room [ROOM NUMBER] and stated they could not tell if the droppings were old or new.
During an interview on 11/12/24 at 9:03 AM, Certified Nurse Aide #2 stated the last time they saw a mouse in the nursing home was about one month ago.
During an interview on 11/12/24 at 9:05 AM, Resident A stated they had seen a couple of rodents in their room. The last time they saw a rodent in their room was about one month ago. Resident A stated they were also concerned about Resident B's room, where they had seen a few mice. They stated they observed mice running over Resident B's feet. Resident A stated staff did not clean under residents' beds.
During an interview on 11/12/24 at 9:12 AM, Registered Nurse Unit Manager #1 stated they had seen rodents on the Third Floor. Originally, the problem was pervasive, with complaints all the time, and there was evidence of rodents that they discovered in their office. They stated lately they had noticed some improvement, with fewer resident complaints, but about one to two weeks ago, they personally observed a rodent running behind a chair inside Resident room [ROOM NUMBER]. Registered Nurse Unit Manager #1 stated they encouraged residents who liked to keep snacks in their rooms to utilize plasticware for storage and they provided plasticware to residents who needed it.
During an interview on 11/12/24 at 9:23 AM, Resident C stated they saw a mouse in their room a couple of days ago, it ran across the floor and under the chair.
During an interview on 11/12/24 at 1:50 PM, Resident D stated they used to live in the country, and mice did not bother them, but they found mice to be unnerving. Resident D stated mice came into their bedroom from the hallway, and they were very fast. They stated about three to four months ago, there were major rodent problems in the facility, and they had noticed some improvement, but the facility still needed a cat to capture the mice. Resident D stated the last time they saw a rodent in their room was two months ago, but they've heard staff screaming when they've discovered a rodent elsewhere on the unit.
During an interview on 11/12/24 at 1:55 PM, Resident E's family member, who was visiting the facility, stated the last time they personally observed a rodent in their family member's room was about two weeks ago, but Resident E reported to them that they saw mice more frequently. The visitor stated Resident E told them they saw a mouse in their room the night before last. The visitor stated they personally brought in rodent traps and placed them in Resident E's room. They had seen rodent droppings in the room and had cleaned them up. They added that the mice were very little, and they had seen them stuck on their traps. Over the last six months, there had been at least six caught on the traps.
Observation on 11/12/24 at 2:00 PM revealed six rodent droppings were on the floor to the left of the heat register inside Resident room [ROOM NUMBER].
During an interview on 11/12/24 at 2:03 PM, Resident F stated they observed one rodent last night on their bed while they were sitting on a chair beside the bed. Resident F stated they let the nurses know, and they screamed, and the whole floor probably heard it. They stated a couple of weeks ago, they had seen two rodents at the same time on the floor in their room. They stated they had lived here about one year, rodents had been an issue for the last three months, and Resident F further stated, It was scary, I don't care for them.
During an interview on 11/12/24 at 2:11 PM, Resident G stated they saw one mouse about one week ago in their room. Resident G described the mouse as little and stated it ran across the room. They stated they first noticed mice in their room about four months ago, total at least ten observed in this room. Resident G stated the mice usually went under the heat register. They stated more recently, they started seeing itty bitty ones, which were probably the babies. When a new extermination company started, they stated they could hear mice in the walls of their room, which sounded like the mice were fighting, but lately, they had not heard any mice in the walls. Resident G stated they had only seen a few rodent droppings in their room since then, and they were probably old droppings that were leftover. They stated they had crackers in a basket in their room, and rodents tore a mayonnaise packet and ate the crackers, but their room had been cleaned out since then.
1b. Observations and interviews on the Second Floor were as follows:
During an interview on 11/12/24 at 9:35 AM, Resident H stated everybody had seen mice in this building. Mice were going from one side of the room to the other under the heating vent. Resident H stated it had been about a month since they saw a rodent in their room, but they recently heard noises in the ceiling that they believed were mice scattering. They further described the noises as three to five mice running back and forth mostly at night.
During an interview on 11/12/24 at 9:45 AM, Resident I stated they had seen and heard mice in their room, and stated, There are too many mice in here. Resident I stated they asked Environmental Services staff to move their chair while cleaning their room on Sunday, and there were rodent droppings under the chair. Resident I stated they observed a mouse in their room the other day and their family brought in their own rodent traps.
Observation on 11/12/24 at 9:48 AM revealed eight to ten rodent droppings were observed on the floor in Resident room [ROOM NUMBER], to the right of the heat register. Two three-tier plastic bins were in this room. One of the three-tier plastic bins had approximately 30 rodent droppings in the bottom drawer. This drawer contained several ripped bags of Ramen noodles. One bag of Ramen noodles contained no noodles but contained approximately 50 rodent droppings. In the bottom drawer was a sealed can of soda and six to seven rodent droppings were observed on the top rim of the can. The other three-tier plastic bin had food in hard sealed containers in the bottom drawer, with one rodent dropping on top of a metal food tin. Also observed in this room were three rodent bait boxes (small plastic boxes that contained a solid brick of poison) on the floor. One of the three rodent bait boxes had poison that was partially consumed, as observed through the clear lid. Additional observation revealed one of the bait boxes had eight to ten rodent droppings on the floor around it.
During an interview on 11/12/24 at 9:51 AM, Licensed Practical Nurse #1 stated they had personally seen rodents on the Second Floor. They stated residents complained frequently they were seeing rodents in their rooms. They stated food had been placed in sealed containers and mass deep cleaning was done a few weeks ago, with a focus on rooms where the residents kept snacks and candy. At this time, Licensed Practical Nurse #1 observed the three-tier bins inside Resident room [ROOM NUMBER] and stated a rodent got into these drawers. They stated they must notify the Unit Manager, clean the area, throw the food out, and get some more containers for this resident's food.
During an interview on 11/12/24 at 10:03 AM, Resident J stated rodents had been running around off and on and the last time they saw a rodent in the facility was last week.
During an interview on 11/12/24 at 10:10 AM, Resident K stated they had found three mice recently, but could not recall the exact date. They stated they told the nurses and the aides about it. They stated a couple of days ago, their family member visited and found rodent droppings inside the locked drawer of their nightstand. Resident K stated their family member cleaned the drawer and threw out the candy that was in it. Resident K stated, This place is infested with rats and mice, agh get them out of here.
Observation on 11/12/24 at 10:12 AM revealed the nightstand inside Resident room [ROOM NUMBER] had two open shelves. There were rodent droppings on both shelves, inside two open-top boxes and on top of papers that were on these shelves. There was a box of chocolates on one of the shelves with six rodent droppings on top of the box.
During an interview on 11/12/24 at 10:15 AM inside Resident room [ROOM NUMBER], Registered Nurse Unit Manager #2 stated those were rodent droppings on the shelves of the nightstand. They stated the chocolates must be thrown out and the area washed. Registered Nurse Unit Manager #2 stated they would inform the Director of Environmental Services, who kept track of pest sightings. Additionally, they stated they had not personally seen a rodent in the facility in about a year but had heard complaints from residents.
During an interview on 11/12/24 at 2:24 PM, Resident L stated baby mice ran up and down the hall, and if their door was open, the mice popped in, and it was all very fast. They stated they last saw a mouse about a week ago. Resident L stated, baby mice don't bother me, I used to have a pet mouse, they don't scare me, but I don't like them unexpectedly, they can jump.
1c. Observations and interviews on the First Floor were as follows:
During an interview on 11/12/24 at 10:38 AM, Resident M stated they had seen mice two different times a couple of weeks ago. They stated they could not say for sure if it was two different mice, but they reported it to staff. They added the mice ran across their room both times, ran under the bed to under the chair. Resident M stated they did not like mice, and they were uncomfortable that mice were around. They added that there was nothing they could do, except report it.
Observation on 11/12/24 at 10:48 AM revealed a small number of rodent droppings were observed on the windowsill and behind a tan storage cube to the left of the window inside Resident room [ROOM NUMBER].
During an interview on 11/12/24 at 10:51 AM, Resident N stated they had seen mice in their bedroom, most recently three days ago. Resident N reported the mice had been observed running on the floor between the dresser, the chair, the bed, and the nightstand, and they were very quick. They stated the dresser was their own personal furniture and no one had ever moved it to clean underneath it. At this time, Resident N stated they heard mice in the walls at night. They stated they were afraid to get up to walk at night because they might step on a mouse and were afraid of sitting with their feet on the floor during the day. They stated the mice showed up indiscriminately, and they didn't know when they would show up next. Resident N stated they were worried because they had a weak immune system and they did not want to get some sort of disease from having mice around. Additionally, Resident N stated, I never had mice in my own home, I wouldn't stand for it.
During an interview on 11/12/24 at 11:02 AM, Certified Nurse Aide #3 stated they had not personally seen any rodents on the First Floor but saw a live mouse in the Second Floor Dining Room about a month and a half ago.
During an interview on 11/12/24 at 11:13 AM, Environmental Services Aide #1 stated they had not observed a rodent in the nursing home but had seen rodent droppings in the resident rooms at the ends of the halls in the north and south halls. They stated when they saw rodent droppings, they swept, mopped, and informed the Director of Environmental Services.
During an interview on 11/12/24 at 11:16 AM, Certified Nurse Aide/ Unit Clerk #4 stated they had seen rodents in the facility. They stated about one month ago, they heard a mouse in a trap making noise inside a resident room, but the resident was not in their room at that time. They stated the room had been deep cleaned and was vacant at this time. They further stated they once observed a rodent running from one side of the hallway to the other but could not recall when.
During an interview on 11/12/24 at 2:25 PM, Resident O stated they had been at the facility for three weeks and in that time, they had observed one small gray mouse and a baby brown rat. Both times, they came out of their bathroom and followed the wall over to the heat register. Resident O stated they used to live in the country and at their home in the country, they occasionally had mice in the garage, but not in the house. They added that mice don't scare them, but they don't like living with them.
During an interview on 11/12/24 at 2:40 PM, Resident P stated they had seen mice in the building, but it had been about three to four months since they saw one. The mice usually came into their room through the hallway door and ran along the baseboard. Resident P stated, I'd like to keep them out, I don't like them in here.
1d. Observations and interviews in the Main Kitchen were as follows:
During an interview on 11/12/24 at 11:23 AM, the Food Service Director stated there had been a rodent issue in the kitchen for a couple of months, it had improved greatly recently, but they were still struggling a little bit with it. They stated Maintenance staff had sealed up possible entry points at the loading dock and condiments and bread were now kept in coolers overnight. Despite the changes made, dry storage remained an issue. The Food Service Director stated staff cleaned under equipment and under shelving at least once per week for dry storage and about every other week under the cooking equipment located under the extinguishment hood.
Observation in the Main Kitchen on 11/12/24 at 11:30 AM revealed a cardboard box of rice pilaf was located on the floor on the left side in the smaller dry storeroom. At this time, the Food Service Director picked up the box and observed it had a hole in it that was approximately one-eighth of an inch in diameter. There were approximately 25 rodent droppings on the floor around where the box was located. The Food Service Director stated the hole in the rice pilaf box was likely caused by rodent chewing, especially because of the rodent droppings on the floor around it. Additionally, on the left side of the room on the floor were empty plastic crates. When the plastic crates were moved, approximately 25 rodent droppings were observed underneath them. The Food Service Director stated they could not tell if the rodent droppings were old or new, but this room should be swept daily, and it was possible that staff were not moving the crates when they swept. Additional observation revealed on the floor under the shelving on the right side of the smaller dry storeroom was approximately 30 rodent droppings, from one end of the room to the other.
Observation in the Main Kitchen on 11/12/24 at 11:40 AM revealed approximately ten older, dusty-looking rodent droppings were observed on the floor behind the door in the main dry storeroom. Near the door of the main dry storeroom were boxes of plastic utensil packets sitting on plastic crates. Under one of the crates, approximately 25 rodent droppings were observed. At this time, the Food Service Director stated staff should be moving the crates when they mopped and swept. The miscellaneous shelf in the corner near the door had approximately ten rodent droppings near its rear wheel. Additional observation in the main dry storeroom revealed there was a large, canned goods rack that was stationary. Approximately 40 rodent droppings were observed under the canned goods rack. The Food Service Director stated staff should clean as often as necessary under this rack, perhaps weekly, and it needed to be cleaned now. The Food Service Director added that the main dry storeroom was where they noted the greatest amount of rodent activity, and they relayed the information about rodent sightings to the exterminator. At the entrance of this room was a stainless-steel rack with oats, syrup, and spices. On this rack, there was one opened box, with sealed syrup bottles inside, with approximately five rodent droppings in the box. There was an unopened box of syrups bottles, with four rodent droppings on top of unopened box. Additional observation revealed there were approximately 20 rodent droppings under this rack at both rear wheels. On this rack was a tipped-over red bucket with a dry white rag inside. The white rag had approximately 30 rodent droppings on it. At this time, the Food Service Director stated the red bucket was for sanitizing solution, and they were not sure why it would be on this shelf. Additional observation in the graham cracker corner of the main dry storeroom revealed there was a white cardboard glue trap on the floor with a large bug in it. The trap was dated 10/25/24 with marker. The Food Service Director stated the glue traps should be checked more frequently because they had been seeing that bug for a while. There were two plastic bin lids located in the graham cracker corner, light blue and light pink, that each had approximately ten rodent droppings on top. There were also rodent droppings observed on the floor under the graham cracker corner. Additional observation in the graham cracker corner of the main dry storeroom revealed a plastic cole slaw container was on the floor with a hole cut in the center and pink sand-looking material in it. Rodent droppings were observed in the pink sand-looking material and on the floor around the container. The Food Service Director stated the Director of Environmental Services made it and they were not sure what the sand-looking material was. There were two rodent boxes on the floor in the catering trays corner of the main dry storeroom. Approximately 30 rodent droppings were observed around these rodent boxes. At this time, the Food Service Director stated there was no poison in the boxes and they were aware of the droppings near the boxes and did not sweep it on purpose so the exterminator could see the rodent activity. At this time, the Food Service Director stated the situation was frustrating.
Observation in the Main Kitchen on 11/12/24 at 12:06 PM revealed the floor under the disposal across from the three-bay sink had a large amount of black debris, mostly under a plastic crate. The Food Service Director stated they were not sure what it was, but the area needed to be cleaned. On the floor under the three-bay sink was a thick tan substance. The Food Service Director stated the floor under the three-bay sink needed to be cleaned. On the bottom shelf of the stainless-steel rack to the left of the disposal was a single ketchup packet. The ketchup packet had a small hole in it, approximately one-eighth of an inch in diameter. Additional observation revealed under the ketchup packet on the floor were approximately 25 rodent droppings. At this time, the Food Service Director stated areas with food had been their focus, and this area of the Main Kitchen was not used at all. They stated rodents liked condiment packets, which was why they recently began storing them in the cooler overnight and a rodent likely moved this ketchup packet, as it would not normally be in this area of the kitchen. Additional observation revealed the floor under the two-bay sink had approximately 20 rodent droppings and an empty cheese box on the floor with two rodent droppings on top of the box. To the right of the two-bay sink was a bucket with a white towel over it. The bucket contained a layer of grease on the bottom and sides, and the towel had approximately ten rodent droppings on it. The Food Service Director stated someone probably just left the bucket there and should not have, as it needed to be cleaned. To the right of the two-bay sink was a storage alcove. There were approximately eight rodent droppings observed on the floor in the storage alcove. There was a three-door cooler in the vicinity of the two-bay sink. The area behind this three-door cooler was split into two sections. Observation revealed one section had tan and black debris on the floor that could not be identified, and the other section had approximately ten rodent droppings on the floor. The Food Service Director stated they could not say the last time someone cleaned behind this three-door cooler.
Observation in the belt line room, off the Main Kitchen, revealed there were approximately 30 rodent droppings on the floor under stainless-steel racks of single service utensils. On the floor under stainless-steel racks of nutritional shakes were approximately ten rodent droppings located under an empty plastic crate. In the belt line room, there was a white cardboard glue trap on the floor under the cereal rack with a large bug in it. The trap was dated 10/25/24 with marker. The Food Service Director stated the bug had been in this trap for over a week and the exterminator needed to address this. In this same area of the belt line room was an opened box of garbage bag liners with six rodent droppings on the box. Further observation revealed the belt line was in the center of the room and under it at one end was a black substance on the floor. The Food Service Director stated they had cleaned this floor last week with a scraper, it was clean then, and they were not sure what the black substance was. Behind cooler #10 in the belt line room, several small butter containers and small scrap pieces of debris were observed. The floor to the left of cooler #10 had a concentrated area of approximately 15 rodent droppings in a three-inch diameter space, and more droppings were scattered in the general area, which was under the hand wash sink. The Food Service Director stated cooler #10 could not be moved and staff didn't normally clean behind it. They stated the butter containers and scraps were likely dragged behind the cooler by rodents because there was no other way the items would get back there. Additional observation in the belt line room revealed the floor behind the miscellaneous cart in the corner had approximately ten rodent droppings. The Food Service Director stated the cart did not get moved.
Additional observation in the Main Kitchen revealed approximately ten rodent droppings on the floor between the blender table and the white refrigerator. Behind the white refrigerator, there were several drink lids and straws and one butter container. On the floor to the left of the white refrigerator was one ripped ketchup packet. In the Main Kitchen, there was a white cardboard glue trap behind the rolling bins of flour. The glue trap was undated and contained a mix of rodent droppings and bugs. At this time, the Food Service Director stated the trap had been there for a while and the exterminator should be replacing it. Additional observation revealed the far corner of the Main Kitchen had black debris on the floor around the ice machine that could not be identified.
1e. Observations and interviews at the loading dock were as follows:
Observation at the loading dock on 11/12/24 at 11:57 AM revealed the back door was propped open with piece of wood, and it was open two inches wide for the length of the door. The screen door did not fit tightly into the door frame and had a gap of one inch wide at the opening edge for the length of the door. There was no one was in the vicinity at this time.
1f. Observations and interviews at the exterior grease storage area were as follows:
Observation outside of the loading dock area on 11/12/24 at 12:00 PM revealed used kitchen grease was stored in an enclosed grease dumpster. The top ledge of the grease dumpster had a layer of greasy debris on half of it. Three of four sides of the grease dumpster had greasy surfaces and appeared wet. Continued observation revealed the left side had grease build-up than the other sides. The Food Service Director stated Maintenance staff power washed the grease dumpster as needed, and it needed another power washing now. Observation of the ground around the grease dumpster revealed the area downstream of grease dumpster appeared wet in an area that measured four feet long by three feet wide. At this time, the area was in full sun and the surrounding area appeared dry.
1g. Observations and interviews at the exterior garbage storage area were as follows:
Observation outside of the building on 11/12/24 at 3:03 PM revealed there was a garbage compactor, two recycling dumpsters, and one open-top construction dumpster. The open-top construction dumpster was completely filled with bagged garbage. At the time of the observation, the Director of Environmental Services stated normally, the open-top dumpster was only for construction and large items, but this morning, the garbage compactor was not working, and staff had to place regular garbage in the open-top dumpster. They further stated the compactor was again operational at this time and a call had already been placed to the garbage collection contractor, and the open-top dumpster was scheduled to be picked up by tomorrow morning. The Director of Environmental Services further stated the garbage compactor had not functioned a few times recently and although it was not ideal, the open-top dumpster had to be used for regular garbage while the compactor was down.
During an interview on 11/12/24 at 2:46 PM, the Director of Environmental Services stated rodent sightings started around June 2024 with resident complaints and staff spotting them. They stated each complaint was logged in the Pest Sighting Log for communication with the exterminator. The facility had also placed their own cardboard glue traps in some areas for extra coverage. The exterminator was coming once per week, but the problem was not getting better, so the facility switched exterminating companies around September 2024. Exterminator visits were later increased to two times per week. They stated they were not sure of the cause of the issue, but holes in the structure of the building could act as rodent entry points. Maintenance staff addressed the holes and the exterminator continued to address the exterior of the building with bait boxes. The Director of Environmental Services stated the situation with the rodents was starting to get under control over the last month, as complaints from staff and residents had lessened. They stated constant reinforcement was needed to ensure residents' personal food was protected and properly disposed of. The Director of Environmental Services stated only Dietary staff cleaned the kitchen, Environmental Services staff were not assigned to kitchen areas. The home-made rodent trap in the main dry storeroom was created as an extra effort, as they were at wit's end with this issue. They stated the substance was a mixture of cocoa powder, mashed potato flakes, and baking soda. The mixture was supposed to attract mice and kill them if they ate it but would not harm people. They placed the home-made trap in the main dry storeroom two weeks ago. They stated when they checked it last week, there were no droppings in or around it, and they had yet to check it this week. The Director of Environmental Services stated floors in the nursing home were cleaned everyday by Environmental Services staff, with a dust mop then a wet mop. Environmental Services staff should be cleaning behind furniture at least once per week. They stated each Environmental Services Aide could pull five to six rooms per day, and pull meant moving furniture and cleaning around all furniture. The Director of Environmental Services stated the rodent issue was wide-spread and affected the entire neighborhood.
During an interview on 11/12/24 at 3:32 PM, the Administrator stated the exterminator continued to come to the facility two times per week Rodent traps were recently changed in all resident rooms to the black box type, and all bait boxes outside were updated. There have been fewer sightings that they had been notified of recently, with no sightings reported to them since last week. The Administrator further stated they were not aware of the situation with the compactor, garbage should be in the

Based on observation, interview, and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure that PRN (as needed) orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order for one (Resident #85) of five residents reviewed for unnecessary medications. Specifically, PRN Ativan (a psychotropic antianxiety medication) was ordered longer than 14 days and there was no documented provider rationale to extend the order or the duration of the order.
The finding is:
The policy and procedure (P&P) titled Use of Psychoactive Medications dated 12/2021 documented each resident's drug regimen must be free from unnecessary drugs. These guidelines shall illustrate the processes in long term care to ensure that each resident is free from unnecessary psychoactive drugs while maintaining his or her optimal physical and mental health. A psychoactive medication is defined as any medication whose primary function is to treat disorders of thought process, mood, behavior, or sleep.
The P&P titled Medication Regimen Review (MRR), Drug Regimen Review (DRR) dated 10/2018 documented Psychotropic drugs include any drug that effects brain activities associated with mental processes and behavior. PRN orders for psychotropic drugs should be limited to 14 days unless the primary care provider reviews and evaluates and documents the rational for extension.
1.Resident # 85 had diagnoses including dementia with behavioral disturbances, hypertension (high blood pressure), and prostate cancer. The Minimum Data Set (MDS-a resident assessment tool) dated 6/8/23 documented Resident #85 had severe impaired cognition and had no behavioral symptoms.
The Comprehensive Care Plan (CCP) revised 6/26/23 documented Resident #85 had behaviors that consisted of verbal aggression, refused care, and was resistive to redirection. The CCP documented the resident was socially inappropriate at times. Ativan was started on 6/23/23 Q (every) 12 hours PRN (as needed) for agitation.
The progress note dated 5/17/23, written by Psychiatric Nurse Practitioner (NP) #1 documented Resident #85 had no anxiety or depression and no need for pharmacological interventions. There were no further psychiatric progress notes in the medical record from 5/18/23 to 8/22/23.
The Nursing Progress Notes dated 6/23/23 at 5:25 PM, Registered Nurse (RN) #1 Unit Manager (UM) documented Resident #85 was agitated, verbally aggressive, difficult to redirect and refused activities. Ativan 0.5mg (milligrams) Q (every) 12 hours was ordered.
The Medication Orders dated 8/18/23 revealed an active order for Ativan 0.5 mg every 12 hours prn for agitation. The start date was 6/23/23. The stop date was 8/22/23.
The Medication Administration Record (MAR) printed on 8/21/23 at 9:20 AM, revealed Ativan 0.5mg Q 12 hours PRN was administered on the following dates: 6/27/23, 7/4/23, 7/6/23, 7/7/23, 7/8/23, 7/19/23,7/23/23, 7/27/23, and 8/5/23.
The Monthly Medication Regimen reviews dated 6/27/23 and 7/26/23 revealed the Consultant Pharmacist documented no clinical interventions were required, and a provider response was not required. There was no documentation the Consultant Pharmacist identified the resident was ordered PRN Ativan beyond 14 days or that this was discussed with a medical provider.
The Medical Directors Progress Notes revealed the following:
-6/27/23 at 4:34 PM, documented no psychotropic drug use or behaviors.
-8/13/23 at 5:48 PM, documented no psychotropic drug use or behaviors. There was no rationale documented by the medical provider for the continued use of the Ativan beyond 14 days and they did not indicate the duration for the PRN order.
During intermittent observations from 8/16/23 to 8/18/22 between the hours of 9:00 AM and 3:00 PM, and 8/21/23 to 8/22/23 between the hours of 9:00 AM and 3:00 PM, Resident #85 was observed self-propelling in their wheelchair and had no behaviors.
During an interview on 8/22/23 at 8:31 AM, RN #1 UM stated Resident #85 called out, screamed and was difficult to redirect. PRN Ativan was ordered on 6/23/23 for agitation for 60 days. RN #1 UM stated there was no documentation by the Medical Director or NP #1 that reflected the use of the PRN Ativan. RN #1 UM stated the Ativan should have been ordered for no more than 14 days.
During an interview on 8/22/23 at 9:01 AM, the Medical Director stated they had no recollection of Resident #85 having aggression and could not recall documentation from the IDT (interdisciplinary team). PRN psychotropic medications should be ordered for a 14-day duration then must be reevaluated and they must have overlooked it. The Medical Director stated they relied on information received from the Unit Manager. The Medical Director stated the UM never told them that the 14-day duration had been exceeded or that the PRN Ativan needed to be re-evaluated for the appropriateness.
During a telephone interview on 8/22/23 at 10:20 AM, the Consultant Pharmacist stated Resident #85's monthly reviews were done on 6/27/23 and 7/26/23. The PRN Ativan should have been reviewed by the provider, reevaluated, or discontinued after 14 days. The Consultant Pharmacist stated there was no documentation from NP #1 or the Medical Director and that's the missing piece.
During a telephone interview on 8/22/23 at 10:35 AM, NP #1 stated the PRN Ativan was for verbal aggression and that Resident #85 was distressed. NP #1 stated they would normally order the PRN Ativan for 14 days, but somehow it was entered incorrectly. There was no written rationale or evaluation on my part. NP #1 stated Resident #85's behaviors improved, the PRN Ativan was unnecessary, and should have been discontinued after 14 days. The NP #1 stated the requirements (for PRN psychotropic medications) were not discussed and they were new to the process.
During an interview on 8/22/23 at 12:05 PM, the Director of Nursing (DON) stated PRN psychotropic medications were reviewed after 14 days. The medical provider determined the benefit, and the appropriate use of the medication. A rationale from the ordering physician should have been documented in the medical record on 6/23/23. The PRN Ativan should have been reevaluated by the ordering physician on 7/9/23 and was not done.
During an interview on 8/22/23 at 1:25 PM, the Administrator stated the PRN Ativan was discussed during BMARC, the Medical Director or NP #1 should have documented in the resident medical record. The Consultant Pharmacist should have identified the timeframe during the monthly review for Resident #85.
10 NYCRR 415.12(l)(2)

Based on interview and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and Director of Nursing (DON), and that these reports were acted upon for one (Resident #85) of five residents reviewed for drug regimen reviews. Specifically, the Consultant Pharmacist did not identify the continued use of a PRN (as needed) Ativan (a psychotropic antianxiety medication) for two months and report the irregularity.
The finding is:
The policy and procedure (P&P) titled Use of Psychoactive Medications dated 12/2021 documented each resident's drug regimen must be free from unnecessary drugs. These guidelines shall illustrate the processes in long term care to ensure that each resident is free from unnecessary psychoactive drugs while maintaining his or her optimal physical and mental health. A psychoactive medication is defined as any medication whose primary function is to treat disorders of thought process, mood, behavior, or sleep.
The P&P titled Medication Regimen Review (MRR), Drug Regimen Review (DRR) dated 10/2018 documented the consultant Pharmacist identifies irregularities through Medication Administration Records (MARs), prescribers' orders; progress notes of prescriber; nurses, and or consultants; behaviors monitoring information; and the attending physician. The consultant pharmacist's evaluation includes but is not limited to reviewing a written diagnosis, indication, or documented objective findings that support each medication order; as needed (PRN) orders including indications for use; documentation by the physician, nurse, and consultants. Psychotropic drugs include any drug that effects brain activities associated with mental processes and behavior. PRN orders for psychotropic drugs should be limited to 14 days unless the primary care provider reviews and evaluates and documents the rationale for extension.
1.Resident #85 had diagnoses including dementia with behavioral disturbances, hypertension (high blood pressure), and prostate cancer. The Minimum Data Set (MDS-a resident assessment tool) dated 6/8/23 documented Resident #85 had severe impaired cognition and had no behavioral symptoms.
The Medication Orders dated 8/18/23 revealed an active order for Ativan 0.5mg (milligram) every 12 hours prn for agitation. The start date was 6/23/23. The stop date was 8/22/23.
The Medication Administration Record (MAR) printed on 8/21/23 at 9:20 AM, revealed Ativan 0.5mg Q 12 hours PRN was administered on the following dates: 6/27/23, 7/4/23, 7/6/23, 7/7/23, 7/8/23, 7/19/23,7/23/23, 7/27/23, and 8/5/23.
The progress note dated 5/17/23, written by Psychiatric Nurse Practitioner (NP) #1, documented Resident #85 had no anxiety or depression and no need for pharmacological interventions. There were no further psychiatric progress notes in the medical record from 5/18/23 to 8/22/23.
The Psychotropic Medication Review dated 6/25/23 at 11:01 AM, completed by the DON, revealed no documentation that Resident #85 was ordered PRN Ativan or that they had any behavior issues.
The Monthly Medication Regimen reviews dated 6/27/23 and 7/26/23 revealed the Consultant Pharmacist documented no clinical interventions were required, and a provider response was not required. There was no documentation the Consultant Pharmacist identified the resident was ordered PRN Ativan beyond 14 days or that this was discussed with a medical provider.
The Medical Director's Progress Notes revealed the following:
-6/27/23 at 4:34 PM, documented no psychotropic drug use or behaviors.
-8/13/23 at 5:48 PM, documented no psychotropic drug use or behaviors. There was no rationale documented by the medical provider for the continued use of the Ativan beyond 14 days and they did not indicate the duration for the PRN order.
During a telephone interview on 8/22/23 at 10:20 AM, the Consultant Pharmacist stated Resident #85's monthly reviews were done on 6/27/23 and 7/26/23. The PRN Ativan order was appropriate on 6/23/23 for agitation. The Consultant Pharmacist stated the PRN Ativan was discussed with NP #1 during monthly BMARC (Behavior Modifying Agent Review Committee) on 7/19/23 and the decision was made to continue the PRN Ativan, therefore they did not document any irregularities. The Pharmacy Consultant stated they did not document this discussion in the medical record.
During an interview on 8/22/23 at 12:05 PM, the DON stated the Consultant Pharmacist should have identified and sent a recommendation to the provider that the duration of the PRN Ativan for Resident #85 was beyond 14 days. It should have been forwarded to the Unit Manager, the DON, and the Medical Director and was not, therefore it may have not been missed.
During an interview on 8/22/23 at 1:25 PM, the Administrator stated there was no justification documented for the continued use of PRN Ativan for Resident #85. The Administrator stated they would have expected the Consultant Pharmacist to catch something like this during the monthly reviews.
10 NYCRR 415.18(c)(2)

Based on interview and record review during the Standard survey completed on 8/22/23, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified seven (three Housekeeping Attendants, one Diet Technician, one Registered Nurse, one Social Worker, and one Activities Leader) of eleven employees that worked in the facility and were subject to the New York State (NYS) Nurse Aide Registry, had been screened through the NYS Nurse Aide Registry prior to their employment.
The finding is:
Per Part 415 - Nursing Homes - Minimum Standards: Nursing home shall develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of residents and misappropriation of resident property. The facility shall not employ individuals who have had a finding entered into the NYS Nurse Aide Registry concerning abuse, neglect or mistreatment of residents or misappropriation of their property.
The policy and procedure called, Employment, General, revised 1/2022, documented the placement process included: reference checks, credentialing and background checks, including criminal background checks, fingerprinting, and NYS Office of Children and Family Services Statewide Central Register Database check. The NYS Criminal History Record Check, where required, was completed by the Human Resources Department.
The policy and procedure called, Licensure/ Certification, revised 2/2022, documented Human Resources will verify and keep a record for all employees who are required to have licensure/ certification and evidence of disciplinary action at the time of employment. This verification will be documented in the employee file with the date and name of the person who completed the verification. This will be performed for all licensed/ certified/ registered categories listed on the NYS website.
During an interview on 8/18/23 at 1:15 PM, the Payroll/ Human Resources Coordinator stated they checked the NYS Office of Professional Development website to verify license information before interviewing a potential licensed candidate. They further stated they did not check the NYS Nurse Aide Registry for new hires, other than Certified Nurse Aides (CNAs), prior to employment. The Payroll/ Human Resources Coordinator stated they had been performing this job since January 2023 and they were trained to check the NYS Nurse Aide Registry for CNAs only.
On 8/18/23 between 1:15 PM and 2:05 PM, documentation of NYS Nurse Aide Registry verification was requested for the following employees:
-Activities Leader hired 6/8/23
-Diet Technician hired 5/25/23
-Housekeeping Attendant hired 5/9/23
-Social Worker hired 5/8/23
-Registered Nurse hired 4/18/23
-Housekeeping Attendant hired 8/2/22
-Housekeeping Attendant hired 6/23/22
During an interview on 8/18/23 at 2:10 PM, the Payroll/ Human Resources Coordinator stated they had no documentation of a NYS Nurse Aide Registry verification for any of the requested employees.
During an interview on 8/18/23 at 2:45 PM, the Administrator stated the NYS Nurse Aide Registry was checked for CNAs only, and not checked for any other job title.
415.4(b)(1)(ii)(a)(b)

Based on interview and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for one (Resident #29) of one resident reviewed. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #29's wishes.
The finding is:
The policy and procedure titled Resident Choice and Preference revised 12/2016 documented each resident's personal preferences would be honored to maintain quality of life, dignity and maintain a comfortable living environment. Staff will inquire with residents and/or their representative as to residents' personal preferences regarding daily routine such as frequency of showers/baths. Unit Managers or designee will ensure that each resident's preference and choices are included in the development of the Comprehensive Person-Centered Care Plan.
1.Resident #29 had diagnoses including bipolar affective disorder, depression, and diabetes mellitus. The Minimum Data Set (MDS, a resident assessment tool) dated 4/25/23 documented Resident #29 was cognitively intact, required extensive assist of two or more staff members with bathing, and there was no rejection of care. The MDS further documented it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath.
During an interview on 8/16/23 at 10:56 AM, Resident #29 stated they would like two or three showers per week. The resident stated staff never asked them their preferred shower day, time, nor frequency of showers per week and that showers were given according to their room number.
The Closet Care Plan (tool used by staff to guide care) dated 5/4/23 documented Resident #29's scheduled shower day was on Thursdays on the evening shift.
During an interview on 8/18/23 at 12:41 PM, Registered Nurse (RN) #2, Unit Manager (UM), stated the facility policy reflected showers were given once weekly according to the resident's room number. RN #2 UM stated they never asked residents how many showers they preferred. If a resident requested additional showers, they were expected to notify the staff and their preference would be honored.
During an interview on 8/21/23 at 8:02 AM, the Director of Activities stated resident preferences were completed with comprehensive assessments, annually, and significant changes in status. Preferences included whether the resident preferred a shower, tub bath, or bed bath. Unit Managers were responsible and asked residents their preferred frequency of showers per week.
During an interview on 8/22/23 at 8:31 AM, RN #1 UM stated bathing schedules were based on the resident room number. Residents were scheduled for one shower or bath weekly. When a resident wanted an additional bath, residents were responsible to ask for more showers and there was no process in place to routinely ask a resident their shower frequency preference.
During an interview on 8/22/23 at 12:21 PM, the Director of Nursing (DON) stated showers were scheduled weekly unless the resident requested more. Preferences were updated on the care plan on admission, quarterly and as needed by the Unit Manager. The DON stated they expected the UM to ask the resident's shower preferences quarterly during care plan review.
During an interview on 8/22/23 at 1:15 PM, the Administrator stated showers were offered weekly. Unit Managers were expected to ask the residents quarterly and update the resident's preferences including frequency on the plan of care to reflect the resident preferences.
10 NYCRR 415.5(e)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/22/23, the facility did not ensure maintenance of 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 infection for one (Resident #15) of two residents reviewed for infection control practices during personal care and one of one facility water management system. Specifically, staff did not perform adequate hand hygiene and change gloves after touching Resident #15's colostomy (an artificial connection of the bowel to the skin surface) bag and urine collection bag, then proceeded to wash the resident's face and touch items in the environment. Additionally, for facility water samples that were positive for Legionella, the facility did not notify New York State Department of Health (NYS DOH) and institute short-term control measures when control limits were not met. Also, staff that administered the facility's Potable Water Sampling and Management Plan did not notify the facility's Registered Nurse (RN) Infection Preventionist (IP) or Administrator of the positive Legionella water sample test results.
The findings are:
1.The facility Potable Water Sampling and Management Plan, dated September 2017, documented the skilled nursing facility was associated with a private, full service, general medical and surgical hospital, and there was one potable water system that serviced the facility. The Potable Water Sampling and Management Plan also documented the skilled nursing facility will complete sampling and analysis in accordance with the frequencies identified in Appendix 4-B of the regulation, in response to required actions to Legionella culture analysis results, and following the specific time frames identified in Appendix 4-B.
New York State Title 10 Subpart 4-2, Appendix 4-B, documented when the percentage of positive Legionella test sites is equal to or greater than 30%, the facility must immediately institute short-term control measures in accordance with the direction of a qualified professional and notify the department. Short-term measures may include, but are not limited to, heating and flushing the water system, hyperchlorination (temporarily increase the free chlorine residual in a water distribution system, or the temporary installation of treatment such as copper silver ionization (a process that destroys biofilms that can harbor Legionella). Additionally, the water system shall be re-sampled no sooner than seven days and no later than four weeks after disinfection to determine the efficacy of the treatment.
Review of the facility documents titled Infection Prevention Committee meeting minutes dated 11/29/22, 1/17/23, and 2/21/23, revealed there was no documentation that Legionella water samples were discussed or reviewed.
Review of the facility's Legionella sampling records revealed 23 water samples were collected from the facility on 10/28/21 and the outside contracted laboratory report dated 11/8/21 revealed ten of 23 water samples tested positive for Legionella. Further review revealed nine of the 23 water samples were taken from the skilled nursing facility and three of the nine skilled nursing facility samples (30%) tested positive for Legionella.
Ten water samples were re-tested, and the outside contracted laboratory report dated 12/10/21 revealed four of ten water samples tested positive for Legionella.
Review of the facility's Legionella sampling records revealed 23 water samples were collected from the facility on 12/16/22 and the outside contracted laboratory report dated 12/30/22 revealed thirteen of 23 water samples tested positive for Legionella. Further review revealed nine of the 23 water samples were taken from the skilled nursing facility and six of the nine skilled nursing facility samples (67%) tested positive for Legionella.
Twelve water samples were re-tested, and the outside contracted laboratory report dated 2/7/23 revealed one of twelve water samples tested positive for Legionella.
Review of an email from the Chief Engineer dated 8/17/23 at 8:37 AM, revealed they were the facilitator of the Legionella Sampling Plan and there had been no changes to the plan since its inception in 2017.
During a telephone interview on 8/22/23 at 11:50 AM, the Chief Engineer stated in December 2022, they reported the positive water samples to a representative of the local county health department, who referred them to someone else, and they left a voicemail message for that person, but never heard back. At that time, they flushed the system with water for a while and did not use hot water for the flush. The Chief Engineer stated they did not have an exact amount of time that they waited before re-testing, but re-tested samples after the water lines were flushed and ice machine filters were changed. They stated they only re-sampled the locations that tested positive in December 2022. Additionally, they stated they did not have any correspondence with nursing staff about the positive water samples and they did not take instruction from anyone regarding their remediation and re-testing activities, as flushing the water was the standard. The Chief Engineer also stated the same thing happened in 2021 with more than 30% of the water samples testing positive for Legionella, but they could not recall specific details from that time.
During an interview on 8/22/23 at 12:10 PM, the RN IP stated they did not know there was a positive Legionella test in the facility in December 2022. The RN IP stated Maintenance collected water samples and would have expected them to inform the RN IP of Legionella in the water system. They stated that 6 of 9 positive samples was very concerning and they should have been informed. They also stated they did not know what the procedure was for the Legionella positive water samples. The RN IP stated they needed to research this issue then stated if they had known about the Legionella positive tests, they would obtain urine tests, and culture any residents with pneumonia.
During an interview on 8/22/23 at 12:16 PM, the Administrator #1 stated they were the facility Administrator since March of 2023 but expected maintenance to notify them of positive legionella results in the water.
During an interview on 8/22/23 at 2:08 PM, the Infectious Disease Doctor (who consults with the SNF) stated the hospital infection committee meets every other month and stated they were not notified and not aware of the positive water samples from the hospital or the SNF and should have been notified because they were the infectious disease doctor and would have ensured protocols were put in place for residents. The Infectious Disease Doctor stated if they had been consulted, then they would have ensured urine and pneumonia legionella testing was completed. The Infectious Disease Doctor stated there was no specific clinical policy, but they would test everyone and would have expected the facility to ensure corrective actions were completed by maintenance for water management.
During an interview on 8/22/23 at 2:20 PM, the Director of Facilities stated there had been no recent changes in the facility's water system. The Director of Facilities also stated the Chief Engineer was licensed by the city as a Stationary Engineer and worked for the facility on a per-diem basis. The Director of Facilities stated the Chief Engineer gave them the Legionella test results after the re-testing was done, and they shared with the Safety Committee in May or June of 2023 that the annual Legionella testing was done and the results were good, because by that time, the re-testing had occurred and only one water sample had Legionella detected, which was less than 30% positive.
During further interview on 8/22/23 at 2:24 PM, the Administrator #1, stated the SNF and the hospital met together at the infection prevention committee meetings and the SNF did not hold their own meetings.
During a telephone interview on 8/22/23 at 2:30 PM, the prior Administrator #2 stated they were the facility's Administrator from 12/10/22 through end of February, into March of 2023. They stated they would need to refer the measurements of water testing to the Director of Facilities, and would expect to be notified of results, and then have notified the county health department, the IP, and the medical director to inform them on what needed to be done for residents.
2.The policy and procedure (P&P) titled Standard Precautions and Respiratory Hygiene dated 9/2018 documented studies have shown that hand washing is the single most important aspect of infection control and prevention. Hand washing must be practiced faithfully by all personnel without exception. Gloves must be worn whenever exposure to excretions, secretions, urine, or feces. Disposable (single use) gloves must be replaced as soon as practical when contaminated.
Resident #15 had diagnoses including multiple sclerosis (MS - a disease of the brain and spinal cord), neurogenic bladder (a bladder with diminished sensation), and a history of urinary tract infections (UTI). The Minimum Data Set (MDS - a resident assessment tool) dated 6/19/23 documented Resident #15 was cognitively intact, required extensive assistance for hygiene, had an indwelling catheter (a tube inserted into the bladder to drain urine) and a colostomy.
The Plan of Care (POC) with dated 6/23/23 documented Resident #15 required assistance with self-care due to the diagnosis of MS and lower extremity weakness. Interventions included extensive assistance for grooming. The POC documented Resident #15 had an alteration in elimination related to suprapubic catheter, history of UTI and colostomy. Interventions included colostomy care daily.
During an observation of morning care on 8/18/23 at 9:52 AM, Certified Nurse Aide (CNA) #1 donned (put on) gloves and set up a clean barrier with supplies on a tray table next to Resident #15's bed. CNA #1 removed Resident #15's gown and burped (a process of letting air out) Resident #15's colostomy bag by partially removing the colostomy bag, letting the air escape and then placed the bag back onto the site. There was a medium amount of brown matter scattered all around the inside of the colostomy bag. CNA #1 then touched the urine collection bag. Without changing their gloves, CNA #1 submerged a washcloth into the basin of water and proceeded to wash Resident #15's face starting with their eyes and mouth. CNA #1 dried Resident #15's face. CNA #1 repeated the process of washing each body part with a new washcloth and drying the resident with a towel. CNA #1 placed a new gown on Resident #15, stated they needed to get more washcloths, then used their gloved hand to open the door. CNA #1 removed their gloves and did not perform hand hygiene, then exited the room. CNA #1 reentered the room with more linens and donned new gloves and provided catheter care to the resident. LPN #1 knocked on the door and entered the room. LPN #1 donned gloves and applied powder to Resident #15's groin area, then removed their gloves, sanitized their hands, and left the room. CNA #1 washed and dried the resident's backside and repositioned them then gave them their call light. CNA #1 emptied the wash basin, gathered the soiled linen, opened the resident's door with the same gloves used during care, and took the linens to the soiled room, where they touched the door handle to enter. CNA #1 then removed gloves and washed their hands.
During an interview on 8/18/23 at 10:30 AM, CNA #1 stated they only completed hand hygiene at the beginning and end of care. CNA #1 stated they never take off their gloves when giving care. CNA #1 stated there was feces in Resident #15's colostomy bag. CNA #1 stated by not changing their gloves during care, there could be a problem.
During an interview on 8/18/23 at 10:31 AM, Licensed Practical Nurse (LPN) #1 stated they saw Resident #15's colostomy bag during care and there was some stool in it. LPN #1 stated CNA #1 should have removed their gloves and performed hand hygiene after burping the colostomy bag. LPN #1 stated CNA#1 should not have touched the door handle with their gloves on.
During an interview on 8/18/23 at 10:41 AM, Registered Nurse (RN) #1 stated CNA #1 should have washed their hands after burping the colostomy bag. RN#1 stated that was considered cross contamination and could result in pink eye. RN #1 stated even if gloves were not visibly soiled, there would be fecal particles on the gloves and that would lead to an infection.
During an interview on 8/21/23 at 10:34 AM, Nurse Practitioner (NP) #2 stated Resident #15 had a high risk for infection because of a history of UTI and diagnosis of MS. NP #2 stated CNA #1 should have changed their gloves and performed hand hygiene after burping the colostomy bag. NP #2 stated even though the gloves were not visibly soiled, there was still a potential for infection because the gloves were contaminated.
During an interview on 8/22/23 at 9:05 AM, the RN IP stated the colostomy bag was considered a point of contact and a line of infection. The RN IP stated CNA #1 should have changed their gloves and washed their hands after burping the colostomy bag. The RN IP stated it did not matter if the gloves were visibly soiled or not. The RN IP stated the gloves were still contaminated with bacteria after opening the colostomy bag. RN IP stated CNA #1 placed Resident #15 at risk for infection. RN IP stated because of Resident #15's diagnoses of MS, neurogenic bladder and history of UTI, Resident #15 was more prone to infection.
During an interview on 8/22/23 at 9:15 AM, the Director of Nursing (DON) stated it was expected that CNAs knew to change their gloves and perform hand hygiene before, during and after care. The DON stated glove changes when moving from one part of the body to another were part of the basic training for CNAs.
10 NYCRR 415.19(a)(1)
10 NYCRR Subpart 4-2.3, 4-2.4, Appendix 4-B

Based on interviews and record review conducted during a Complaint investigation (Complaint NY#00278522) during the Standard survey completed on 11/23/21, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #1) of two residents reviewed for abuse. Specifically, there was an incomplete investigation completed by the facility to rule out abuse, neglect or mistreatment for a reported allegation that Resident #25 was handled roughly by staff.
The finding is:
The facility policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, misappropriation revised 10/19, documented reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of property) were promptly and thoroughly investigated. The investigation would try to determine what happened and designated personnel would begin the investigation immediately. The investigation would include resident's statements, involved staff and witness statements of events, observation of resident and staff behaviors during the investigation.
1. Resident #25 had diagnoses including paraplegia (paralysis of legs/lower body), anxiety, and depression. The Minimum Data Set (MDS-a resident assessment tool) dated 6/21/21 documented Resident #25 had moderately impaired cognition
Review of a Nursing Progress Note written by Registered Nurse (RN) Supervisor #2, dated 6/26/21 at 11:01 AM revealed Resident #25 was upset that morning, stated they had a rough night and morning. Expressed they wanted to get up every day and not go to bed at 3:00 PM. The resident was assured by the RN (#2) they would follow up with staff to ensure the resident's wishes were honored. The resident had some other concerns with staff, was offered a room change and the resident declined. Complaints were forwarded to the Administrator.
Review of an email from RN Supervisor #2 to the Administrator dated 6/26/21 at 11:35 AM, revealed Resident #25 was upset that morning and wanted to get out of bed. The resident stated the aides told the resident they were short staffed and today wasn't the resident's day to get up. The resident stated the aide grabbed them by the arm to turn them in bed and was rough. The RN assured the resident the staff would get them up, but the resident didn't want the supervisor to tell the aide because the resident was afraid. The RN Supervisor then called the Administrator. The RN documented that they offered the resident a room change, but they declined.
Review of the HERDS: NH Incident Form-NH dated 6/26/21 at 1:00 PM (provided by the Administrator), revealed Resident #25 was fearful to the RN Supervisor #2 on day shift, stating they wanted to get out of bed, but was told 'no' by one of the aides. Resident #25 could not recall specific names of staff members. The resident showed signs of anxiety, fearfulness in regard to their care, and answering call lights. The RN Supervisor offered the resident a room change to have different staff members care for them and the resident declined. The investigation was on-going. There were no staff statements included.
Review of the Progress Note - Nurse, written by the Administrator, dated 6/28/21 at 10:30 AM, revealed they spoke with Resident #25 and discussed preferences regarding when they would like to get out of bed. Discussed the concerns resident expressed with the supervisor on 6/26. The resident stated there were no issues with staff, they were all friendly. Sometimes the resident's call light was not answered timely, no reports of abuse/retaliation per the resident.
During an interview on 11/19/21 at 2:00 PM, the Administrator stated the RN Supervisor called on a weekend to let them know about some concerns the resident had and the Administrator reported it (to DOH) right away, but when the Administrator talked to the resident on Monday, there was nothing to investigate. The resident brought up bedtimes and call light wait, but no abuse.
During an interview on 11/22/21 at 11:34 AM, Certified Nurse Aide (CNA) #5 stated they didn't remember any incident with Resident #25 from June 2021 and was not asked to write a statement about anything.
During a telephone interview on 11/22/21 at 12:09 PM, the RN Supervisor #2 stated when they (RN Supervisor #2) passed medications to Resident #25 on 6/26/21, the resident was upset and stated they wanted to get out of bed. The resident stated the aides wouldn't get them up because they were short staffed that day. The resident said they were afraid the aides would be upset that the resident reported it. RN Supervisor #2 stated they offered the resident a room change but the resident declined. The RN Supervisor #2 stated they let the Administrator know about the resident's concerns and that the Administrator did not direct them to get staff statements or other resident's statements. The RN did not get staff statements about being rough with the resident, the RN talked to the assigned aide about getting the resident out of bed. The RN Supervisor #2 stated once they told the Administrator about the resident's concerns, it was the Administrator's responsibility to complete the investigation. The RN Supervisor #2 stated the resident was afraid of retaliation. The RN stated the resident said their assigned aide grabbed their arm to turn the resident in bed and was rough. RN Supervisor #2 stated CNA #5 was assigned to the resident that day.
During an interview on 11/22/21 at 3:24 PM, the Director of Nursing (DON) stated they would complete investigations for anything out of the ordinary and that staff and resident interviews should be included in their investigation. Also, any physical findings, resident assessment, room etc. The DON stated an allegation of rough handling would be considered mistreatment and they were not involved in the situation with Resident #25 in June.
During an interview on 11/22/21 at 3:35 PM, the Administrator stated they got an email and call from RN Supervisor #2 saying that Resident #25 didn't get up at their normal time and felt fear of retaliation. The RN Supervisor provided comfort, reassurance. The Administrator stated when they talked to Resident #25 on Monday (6/28/21) the administrator didn't feel it was much of an issue because the resident didn't recall what they reported to the RN Supervisor #2. The Administrator stated they didn't direct the RN Supervisor #2 to get staff statements on 6/26/21 because they weren't needed due to the resident's past medical history. The Administrator stated they didn't feel like they needed to do anything else once they talked to Resident #25 on 6/28/21. The Administrator stated grabbing of an arm would be considered mistreatment and that they didn't follow facility policy which included staff statements.
415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/23/21 the facility did not ensure that residents who use psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #35) of five residents reviewed for unnecessary medications. Specifically, the resident received Seroquel (antipsychotic medication) 50 milligrams (mg) every 12 hours since 1/13/2020 without GDR attempts or a documented reason why a GDR was clinically contraindicated. Also, there was lack of documented behaviors for the ongoing use of the antipsychotic medication.
The finding is:
The facility policy and procedure (P&P) titled Antipsychotic Drugs revised 2/19 documented residents who use antipsychotic drugs receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Within the first year when an antipsychotic ordered the facility will attempt a GDR in two separate quarters. After the first year, GDR must be attempted annually unless clinically contraindicated. Clinically contraindicated for antipsychotics prescribed for dementia with behaviors is defined by: target symptoms returned or worsened after the most recent attempt at a GDR and the physician has documented a rationale why additional GDRs would be likely to impair the resident's function, increase distressed behavior, or cause psychiatric instability.
1. Resident #35 had diagnoses including dementia, history of stroke, and aphasia (loss of ability to understand or express speech). The Minimum Data Set (MDS-a resident assessment tool) dated 9/20/21 documented Resident #35 had severe cognitive impairment, received antipsychotic medication on a routine basis and no GDR had been attempted. The MDS also documented Resident #35 had no behavior symptoms, including hallucinations or delusions.
Review of the Plan of Care dated 9/21/21 revealed Resident #35 was started on Seroquel 25 mg at bedtime on 8/29/19 due to visual and auditory hallucinations. On 9/26/19 the neurologist increased Seroquel to every 12 hours for dementia with hallucinations. On 1/13/2020 the Seroquel was increased to 50 mg every 12 hours due to increased visual and auditory hallucinations. Interventions included staff were to observe behavior and monitor for any adverse effects, review at BMARC (Behavior Management and Recommendation Committee) periodically, and per MD a GDR was contraindicated due to intractable condition (history of stokes). Goals included to explore GDRs per NYSDOH (New York State Department of Health) guidelines.
Review of the LTC All Orders -All Statuses (physician's orders) dated 1/1/2020 revealed on 1/13/2020 Seroquel 25 mg was discontinued, and Seroquel 50 mg every 12 hours was started.
Review of the Behavior Detailed Entry Report (CNA documentation of behaviors) from 11/1/2020 through 11/22/2021 revealed there was one instance of the resident hitting staff on 11/19/2020 at 9:30 AM. There were no other behaviors documented.
Review of nursing progress notes dated 5/1/21 through 11/23/21 revealed there was no documentation of hallucination behaviors.
Review of the physician Progress Note dated 12/14/2020 through 11/3/2021 revealed there was no documentation a GDR would be clinically contraindicated for Resident #35.
Review of the Nurse Practitioner (NP) progress notes dated 11/10/2020 through 11/15/21 revealed the resident had vascular dementia without behavioral disturbance. On 2/26/21 the resident was appropriately tearful and sad that their mother passed away two days ago. There was no documentation the resident had auditory or visual hallucinations. The resident was continued on Seroquel and there was no documentation that a GDR was clinically contraindicated.
Review of the Psychotropic Medication Review dated 6/22/21 at 2:22 PM revealed the resident received Quetiapine (Seroquel) 50 mg every 12 hours since 1/13/2020. There was a pending psychiatric consult secondary to the increase in Seroquel in 1/2021, consult with neurology, interdisciplinary team was to follow up. The provider agreed with the recommendations.
Review of the Psychiatric NP progress notes dated 9/20/21 and 10/25/21 revealed Resident #35 was seen for follow up psychiatric evaluation and medication management. The resident had been doing well with no behavior issues. Medication changes included to discontinue the morning dose of Seroquel if needed.
During an observation of personal care on 11/19/21 at 11:45 AM, two staff members ambulated Resident #35 to the bathroom using a rolling walker with a slow, steady gait. The resident was toileted and incontinence care was provided. The resident was pleasant and exhibited no behaviors or hallucinations.
During an interview on 11/22/21 at 9:49 AM, Certified Nurse Aide (CNA #1) stated Resident #35 was never resistive with care and had no behaviors.
During an interview on 11/22/21 at 9:52 AM, the Registered Nurse Unit Manager (RN UM) #1 stated Resident #35 was started on Seroquel for hallucinations and that a neurologist saw the resident and increased the dosage. The RN UM #1 stated it was pre-pandemic since a neurologist saw the resident and they have not tried a GDR due to visitation restrictions. The RN UM stated there was documentation that the resident had an intractable condition due to a history of strokes and that they didn't have to do a GDR and the physician agreed. The RN UM #1 stated it had been a while since the resident had any behaviors or hallucinations. The RN UM #1 stated the Resident #35 was seen by a psychiatric NP but didn't know if there had been any recommendations made. The RN UM #1 reviewed the psych NP notes from 9/2021 and 10/2021 and stated the Psychiatric NP had not communicated any recommended changes and didn't know what the if needed part of the recommendation meant. The RN UM #1 stated they usually read any consultant's notes but didn't know about the recommendations. The RN UM #1 stated that a GDR wasn't done because the resident had intermittent hallucinations and they didn't want to change anything during the COVID-19 pandemic.
During an interview on 11/22/21 at 2:50 PM, the Consultant Pharmacist stated Resident #35 received Seroquel 50 mg every 12 hours since 1/2020 for vascular dementia. The resident had been seen by a neurologist who made the recommendation and felt it was beneficial that the resident used the medication for hallucinations. The Consultant Pharmacist stated the resident got routine psychiatric services for paranoia and hallucinations. The Consultant Pharmacist stated they had recently made a recommendation to nursing to document evidence of psychosis and behaviors that were a danger to the resident or others and were persistent regardless of non-pharmacological interventions, to ensure the indication for the medication remained appropriate, and to make sure the resident's behaviors met that criteria. If the resident had no symptoms, they were compelled to try a GDR or document why it wasn't done. The Consultant Pharmacist stated they thought a GDR would be detrimental due to the intractable condition, wouldn't want the resident distressed.
During an interview on 11/23/21 at 9:36 AM, the attending Physician stated they relied on the BMARC committee to let them know what needed to be done when it came to GDRs and there's a pharmacist on that committee. The Physician stated they didn't remember if staff reported the resident needed a GDR. The Physician stated an intractable condition was not a diagnosis and that their usual protocol was if a resident was stable with their symptoms, they would try to reduce the psychotropic medication. The attending Physician stated maybe this resident slipped through the cracks.
During an interview on 11/23/21 at 10:58 AM, the Psychiatric Nurse Practitioner (NP) stated they made recommendations on psychiatric medications and the facility usually followed their recommendations. The NP stated with the elderly population they always recommended to decrease antipsychotic medications. Resident #35 wasn't agitated during their visits and was pretty stable, so they made the recommendation to decrease the morning dose. The NP stated they usually communicated with the nurse manager on the unit with any recommendations they made.
During an interview on 11/23/21 at 11:14 AM, the Director of Nursing (DON) stated they were not routinely involved in BMARC meetings and would expect that a provider be notified of any recommendations made by a consultant. The DON stated the providers should document why a GDR was clinically contraindicated. The DON also stated that the documentation wasn't what it should be regarding resident's behaviors.
During an interview on 11/23/21 at 12:21 PM, the Nurse Practitioner stated they had been following Resident #35 for about nine months and the lack of a GDR was my fault as they had lost track of the fact that no GDRs had been done in a while. The NP stated they were not aware of any recommendations made by the Psychiatric NP and relied on staff to be notified of any recommendations. The NP stated they didn't know any reason why Resident #35 should not have had a GDR and didn't know of any distressing behaviors from the resident.
415.12 (1)(2)(c) (ii)