Amsterdam Nursing Home Corp (1992)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that resident dietary preferences were followed. This was evident in 1 (Resident #137) of 2 residents reviewed for Food out of 37 total sampled residents. Specifically, Resident #137 was provided whole milk instead of their documented preference of lactose-free milk.
The findings are:
The facility's policy and procedure titled Menu and Preference Policy with a revised date of 03/2024 documented that menus shall meet the nutritional needs of residents, be prepared in advance, and be followed. Menus and available snacks shall be adjusted to meet individual caloric and nutrient-intake needs of the residents.
Resident #137 had diagnoses that included Osteoarthritis and Chronic Pain Syndrome.
The Quarterly Minimum Data Set, dated [DATE] documented that Resident #137 had intact cognition and required setup and cleanup assistance with eating.
The Comprehensive Care Plan for Nutrition dated 12/31/2024 and reviewed on 03/19/2025 documented interventions which included identifying and honoring food preferences, providing diet and consistency as ordered, and monitoring laboratory results.
The Dietary Progress Note dated 04/23/2025 documented that the Registered Dietician spoke with Resident #137 about food preferences and the preferences were documented in the electronic note to include the resident's preference for lactose-free milk.
The Breakfast and Dinner Tickets for Resident #137 were reviewed and documented that from 04/25/2025 to 04/30/2025, Resident #137 received whole milk instead of lactose-free milk with their breakfast and dinner trays.
On 04/29/2025 at 9:59 AM, Resident #137 was interviewed and stated they have been receiving whole milk instead of lactose-free milk. They stated that they had informed the Registered Dietician of this discrepancy but continued to receive whole milk. An unopened carton of whole milk was observed on Resident #137's breakfast tray.
On 04/30/2025 at 11:00 AM, an unopened carton of whole milk was again observed on Resident #137's breakfast tray in their room.
On 04/30/2025 at 11:11 AM, the Director of Nursing was interviewed and stated that Certified Nursing Assistants were expected to monitor resident food intake and report any concerns to the nurse or dietary department.
On 04/30/2025 at 12:18 PM, Certified Nurse Assistant #3 was interviewed and stated they were aware that Resident #137 did not drink the milk that was served to them on their breakfast and lunch trays but because the resident had not complained to them about it, Certified Nursing Assistant #3 had not reported it to anyone.
On 05/01/2025 at 11:00 AM, the Registered Dietician was interviewed and stated that Resident #137 has preference for lactose-free milk. They stated that due to a technical error, the preference was not updated in their electronic medical system and that was why Resident #137 was still receiving whole milk. The Registered Dietician stated that if a resident is not consuming their meals, Nurses and Certified Nursing Assistants working on the unit are expected to report those concerns to the Registered Dietician to follow up on. The Registered Dietician stated that staff had not reported this concern to them.
On 05/01/2025 at 11:08 AM, the Chief Clinical Dietician was interviewed and stated that Resident #137 was supposed to be receiving lactose-free milk. They stated that a human error occurred when entering the preference into the electronic medical system and that was why Resident #137 had not been receiving lactose-free milk.
10 NYCRR 415.14(c)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that Minimum Data Set assessments accurately reflected each residents' status. This was evident in 2 (Resident # 367 and Resident # 265) of 38 total sampled residents. Specifically, 1.) Resident #367's assessment did not accurately reflect their discharge status and 2.) Resident #265's assessment did not reflect the use of a wander alert device.
The findings are:
The facility policy titled Minimum Data Set 3.0 Clinical Operation with a last reviewed date of 08/2024 documented the facility is to ensure accurate assessment that reflects resident's status and to address all care needed by residents.
1.) Resident #367 had diagnoses that included Anemia, Hypertension, and Muscle Weakness.
Resident #367's discharge Minimum Data Set assessment dated [DATE] documented the resident was discharged to an acute hospital.
A physician notes dated 01/31/2025 documented Resident #367 was to be discharged home on [DATE] and will be living with a family member.
A social services' progress note dated 01/29/2025 documented Resident #367 will be discharged to the community on 02/02/2025.
A nurse's progress note dated 01/31/2025 documented Resident #367 was being discharged on 02/02/2025 to a family member at home in stable condition. The note documented that Resident #367 left the unit accompanied by their family with discharge prescriptions to be filled up in the community pharmacy.
On 05/05/2025 at 11:25 AM, the Minimum Data Set Coordinator was interviewed and stated Resident #367 was discharged to the community and that the discharge status on the assessment was coded incorrectly.
On 05/06/2025 at 12:14 PM, the Director of Nursing was interviewed and stated that Resident #367's discharge status on the assessment has data error and the Minimum Data Set assessment needs to be modified.
2.) Resident #265 had diagnoses of Unspecified Dementia, Nontraumatic Intracranial Hemorrhage, and Seizure.
During multiple observations on 05/01/2025 at 10:05 AM, 05/02/2025 at 10:43 AM, 05/06/2025 at 9:35 AM, Resident #265 was observed wearing a wander alert device on their left ankle.
The Comprehensive Care Plan related to risk for elopement that was initiated 09/28/2023 and was last updated on 04/06/2025 documented to apply a wander alert device starting 09/28/2023.
A physician's order dated 09/29/2023 documented to check wander alert device placement to Resident #265's left leg every shift and functionality daily.
The quarterly Minimum Data Set assessment dated [DATE] documented Resident #265 was severely impaired in cognition, had wandering behavior daily, and had no wander/elopement alarm used.
On 05/02/2025 at 2:04 PM, Registered Nurse #5 was interviewed and stated Resident #265 walks in the hallway and stands in front of elevator almost every day. Registered Nurse #5 stated Resident # 265 had a wander alert device on their left ankle since they were transferred to the unit on 09/29/2023.
On 05/02/2025 at 2:17 PM, the Minimum Data Set Coordinator was interviewed and stated it is their responsibility to schedule the Minimum Data Set assessment, and to ensure completion and submission of Minimum Data Set assessment in a timely manner. They stated there was a coding error in Resident #265's assessment and that the use of wander alert device should have been coded.
10 NYCRR 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. This was evident in 1 (Resident #130) of 2 residents reviewed for Hydration. Specifically, Resident #130 was observed with a soiled dressing on their peripherally inserted intravenous catheter on the left upper extremity.
The findings are:
The facility policy and procedure titled Peripheral Line Dressing Change with a last revised date of 01/2025 documented that the peripheral catheter insertion site is a potential entry site for bacteria that could produce a catheter -related infection. The policy stated transparent dressings are changed every 72 hours with site rotation, or sooner if the integrity of the dressing is compromised (wet, soiled, or loosened). When a transparent dressing is applied over a gauze dressing it is considered a gauze dressing and is changed every 24 hours, or sooner if the integrity of the dressing has been compromised (wet, loose, or soiled). Gauze dressings are changed every 24 hours and sooner if the integrity of the dressing has been compromised (wet, soiled or loosened).
Resident #130 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia and Heart Failure.
The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #130 had severely impaired cognition and was dependent on activities of daily living and mobility.
During multiple observations on 04/29/2025 at 8:52 AM, 2:37 PM, and at 3:00 PM, Resident #130 was observed with a peripherally inserted intravenous catheter on the left upper extremity. The transparent dressing was undated and soiled, and the inner gauze was falling off revealing the catheter insertion site.
A care plan for peripheral catheter was initiated 04/16/2025 with a documented goal that Resident #130 would be free of signs and symptoms of infiltration, phlebitis and dislodgement. The facility interventions included changing the intravenous site every 72 hours and as needed if red, painful, infiltrated or occluded and to monitor site every shift and report any abnormalities to the primary medical doctor.
The physician's orders dated 04/15/2025 documented peripheral line insertion and sodium chloride intravenous solution 0.45%, use 50 milliliters per hour every shift for hydration for 3 days, with a start date of 04/15/2025 and end date of 04/18/2025.
A physician's order dated 04/16/2025 documented intravenous dressing kit, transparent dressing change every week and as needed and gauze dressing change every 48 hours, to apply securement device every dressing change.
A review of the Treatment Administration Record from 04/16/2025 through 04/30/2025 had no documented evidence that Resident #130's peripheral line intravenous dressing was changed.
On 04/29/2025 at 2:42 PM, Registered Nurse #8 was interviewed and stated that Resident #130 had a peripheral intravenous catheter inserted on 04/15/2025 and received intravenous fluids for hydration from 04/15/2025 to 4/18/2025. Registered Nurse #8 stated they had not changed Resident #180's peripheral line dressing and that they observed the dressing was hanging off. They stated the peripheral line dressing must be changed weekly or as needed.
On 04/29/2025 at 3:05 PM, Registered Nurse #6, who was the Unit Manager was interviewed and stated that Resident #130's peripheral line dressing is open and dirty and can place the Resident at high risk for infection. Registered Nurse #6 stated this condition is unacceptable. Registered Nurse #6 stated that the insertion site dressing should be changed every 7 days or as needed.
On 04/29/2025 at 3:30 PM, the Director of Nursing was interviewed and stated that intravenous dressings must be changed every 72 hours or as needed and the site must be monitored for infection.
10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. This was evident in 1 (Resident #74) of 4 residents observed for Pressure Ulcer Injury out of 35 total sampled residents. Specifically, Registered Nurse #8 failed to follow infection prevention and control practices while performing wound care treatment.
The findings are:
The facility policy titled Skin and Pressure Ulcer Injury with a revised date of 06/27/2024 documented that the facility will assess residents for risk in the development or pressure ulcer injuries and implement preventative measures in accordance with current standards of practice.
An Infection Prevention and Control Policy titled Clinical Operations with a revised date of 02/19/2025 documented that staff will be trained on infection control procedures and practices including where and how to find and use pertinent information, procedures, supplies and equipment related to infection prevention and control.
Resident #74 was admitted to the facility with diagnoses that included Non-Hodgkin's Lymphoma and Cerebral Vascular Accident.
The Significant Change Minimum Data Set assessment dated [DATE] documented that Resident #74 had intact cognition, required maximum assistance for care and mobility and required wound care and treatments for 1 unstageable deep tissue injury pressure ulcer.
A Wound Care Evaluation form dated 04/28/2025 documented that Resident #74 was assessed with a Braden Scale score of 13-14 indicating moderate risk for developing pressure ulcer and had an actual Stage IV Sacral Pressure Wound. The evaluation form documented that on 04/28/2024, the Stage IV Sacral Pressure Wound required sharp debridement to prevent infection, promote healing and maintain tissue viability. Post procedure instructions included strict adherence to wound protocols, vigilance for signs and symptoms of infection and other complications. Wound healing and preventative recommendations included infection prevention. The care plan was discussed with the bedside nurse.
A Physician's Order dated 04/29/2025 documented a treatment order of Dakin's ¼ strength irrigation solution (a diluted sodium hypochlorite solution used as an antiseptic for wounds) to be applied topically to the sacral pressure ulcer for cleansing and packing with an application of Anasept (a topical solution of sodium hypochlorite that fights bacteria and prevents or treats infections caused by cuts, ulcers, or surgery) and cover with a bordered gauze every day and evening.
On 05/01/2025 at 11:57 AM, a wound treatment observation for Resident #74 was conducted with Registered Nurse #8. Registered Nurse #8 was observed with donned gloves, removed the soiled dressings from Resident #8's sacral pressure ulcer. After discarding the soiled dressing, without changing gloves and without performing hand hygiene, Registered Nurse #8 proceeded to irrigate the wound by pouring the Dakin's solution directly from the multi-use bottle. Without changing gloves and without performing hand hygiene, Registered Nurse #8 applied the Anasept cream to the wound by using a tongue blade applicator. Registered Nurse #8 applied the Anasept cream twice to the sacral wound, using one tongue blade applicator, with the contaminated applicator touching the opening of the multiuse tube of Anasept cream.
On 05/01/2025 at 12:16 PM, Registered Nurse #8 was interviewed and stated they rushed to perform the wound care and treatment for Resident #74. They stated they did not perform the appropriate infection control practices such as hand washing and changing of gloves after removing the soiled dressing and not reusing applicators to reapply treatment cream to the wound bed. Registered Nurse #8 stated they usually use gauze pads to apply the Dakin's solution to irrigate the wound, but they poured the solution from the multiuse bottle because they wanted the wound to be well irrigated.
On 05/01/2025 at 12:26 PM, Registered Nurse #1, who was the Unit Manager, was interviewed and stated that Registered Nurse #8 should have washed their hands at the initiation of the wound treatment and after the removal of the soiled dressing and should have worn clean gloves to perform the wound treatment. Registered Nurse #1 also stated that Registered Nurse #8 should have used a medication cup or a syringe to irrigate the wound instead of pouring the Dakin's irrigation solution from the bottle and should have used more than 1 applicator to apply the Anasept cream.
On 05/01/2025 at 12:42 PM, the Director of Nursing was interviewed and stated that Registered Nurse #8 should have adhered to the infection control guidelines including changing gloves after removing the soiled dressing and handwashing before initiating wound treatment. The Director of Nursing also stated when performing wound treatment, irrigation solution must not be poured directly from the multiuse bottle and that the single use applicator must not be used twice. The Director of Nursing stated this practice is not acceptable.
10 NYCRR 415.12 (c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that appropriate services, care, and equipment were provided to assure that residents did not experience a reduction in range of motion or received appropriate treatment and services to prevent further decrease in range of motion. This was evident in 1 (Resident #162) of 5 residents reviewed for Rehabilitation and Restorative Care. Specifically, Resident #162 was observed with a left-hand contracture that has not been thoroughly assessed by the facility.
The findings are:
The facility policy titled Contractures with a last revised date of 05/2024 documented that it is the facility's policy to ensure that a resident who is admitted without a limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable, and a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
Resident #162 had diagnoses that included Type 2 Diabetes Mellitus and Depression.
The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #162 had moderate cognitive impairments, had no upper or lower extremity impairments, and required setup assistance with eating, dressing, and personal hygiene.
A Comprehensive Care Plan for Self-Care and Mobility that was last revised on 12/16/2024 documented a goal of Resident #162 remaining free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, and fall related injuries. Monitoring, documenting, and reporting signs and symptoms of immobility such as contractures forming or worsening was listed as an intervention.
A Progress Note documented by the Nurse Practitioner dated 04/15/2025 documented that Resident #162 had complaints of left-hand 5th digit pain with movement/contracted.
A review of the electronic medical record did not reveal any additional documentation related to Resident #162 having a contracture or being referred for any follow up related to the complaints of left-hand 5th digit pain and contracture reported to the Nurse Practitioner on 04/15/2025.
On 04/29/2025 at 09:46 AM, Resident #162 was observed with contracted fingers on their left hand. Resident #162 was interviewed and stated that they developed the contracture in the facility and was upset over the loss of functional ability in the hand. Resident #162 stated that he had notified the provider of his concerns but had only been given two foam balls to squeeze which had not helped to improve mobility. Resident #162 further stated that he had not been evaluated by the Rehabilitation Department related to the contracture.
On 05/02/2025 at 09:04 AM, Certified Nursing Assistant #1 was interviewed and stated that Resident #162 had limited mobility and pain in their left hand. Certified Nursing Assistant #1 stated that this limited the resident's ability to complete activities of daily living independently and led to Resident #162 requiring hands-on assistance with removing their pants when using the bathroom or opening food items on their meal trays. Certified Nursing Assistant #1 stated that they were not sure if this was a recent decline in functional status for Resident #162 that Resident #162 had been complaining about pain in the contracted hand more frequently. Certified Nursing Assistant #1 further stated that they had not notified the Registered Nurse about the contracted hand because they believed that Resident #162 was admitted with the contracture and that the nurses were already aware.
On 05/02/2025 at 09:23 AM, Registered Nurse #1 was interviewed and stated that they believed that Resident #162 had been admitted to the facility with a slight contracture in the left hand. The contracture has led to Resident #162 requiring assistance with most tasks that require the use of both hands, such as dressing or cleaning the skin after toileting. Registered Nurse #1 stated that they believed that the Rehabilitation Department was already aware of Resident #162's left hand contracture.
On 05/02/2025 at 09:30 AM, the Director of Rehabilitation was interviewed and stated that Resident #162 was most recently discharged from rehabilitation services on 12/20/2024. The Director of Rehabilitation stated that there was no documented evidence that Resident #162 had any contractures at that time. The Director of Rehabilitation further stated that if Resident #162 had developed a contracture after they had been discharged from rehabilitation services on 12/20/2024, it would be the Nursing Department's responsibility to alert the Rehabilitation Department of this so that Resident #162 could be referred for a new evaluation.
On 05/02/2025 at 09:58 AM, the Nurse Practitioner was interviewed and stated that Resident #162 had developed a left hand contracture while a resident in the facility. The Nurse Practitioner believed that the resident had had this contracture for about eight or nine months. The Nurse Practitioner further stated that when they had assessed Resident #162 in April 2025, Resident #162 complained about the contracture. In response, the Nurse Practitioner gave Resident #162 a soft foam ball to use for daily hand exercises and informed the resident that there was already an order for as needed Ibuprofen in their chart that could be used if they experienced pain in the contracted hand. The Nurse Practitioner stated that they believed that the Rehabilitation Department was already aware that Resident #162 had a left-hand contracture and that was why they did not notify Rehabilitation or refer Resident #162 to be evaluated by the Rehabilitation Department related to the contracted hand.
On 05/02/2025 at 10:05 AM, the Attending Physician was interviewed and stated that they believed that Resident #162 had the left-hand contracture for a few months but was unable to find documentation related to it. The Attending Physician stated that after Resident #162 complained to the Nurse Practitioner about the contracture in April 2025, the Nurse Practitioner should have referred Resident #162 for an Occupational Therapy evaluation. The Attending Physician stated that it could also potentially be appropriate for Resident #162 to undergo an X-Ray on the hand and receive a new order for a non-steroidal medication to help with the associated pain. The Attending Physician stated that they were not sure why the Nurse Practitioner had not considered these interventions at the time that Resident #162 reported the complaints to them.
05/06/2025 at 10:18 AM, the Director of Nursing was interviewed and stated everyone on the team would be responsible for identifying a new or worsening contracture.
10 NYCRR 415.12 (e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure drugs and biologicals were stored in accordance with professional standards. This was evident in 1 of 6 units observed for medication storage. Specifically, the 3rd Floor unit medication refrigerator was observed to contain an expired COVID-19 vaccine.
The findings are:
The facility's policy titled Medication Storage with a revision date of 01/2023 documented that to provide guidelines for storage of medications within the facility, the center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the resident and is in accordance with the Department of Health guidelines. Expired discontinued or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy.
A Nursing Daily Quality Improvement Audit Tool documented that an audit of the medications in the medication storage room and medication refrigerator should be completed at the beginning of each shift. The refrigerator should be checked at the beginning of each shift and medications may be removed up to 3 days before the expiration date. The medication room should contain no expired stock medications or supplies.
On 05/04/2025 at 3:58 PM, an observation of the 3rd Floor Medication Storage Room and the 3rd Floor Medication Refrigerator was performed with Registered Nurse #9. The 3rd Floor medication refrigerator was observed to contain (1) 0.3 milliliter Comirnaty COVID-19 Vaccine with an expiration date of 03/11/2025.
On 05/05/2025 at 3:14 PM, Registered Nurse #9 was interviewed and stated that before each shift change the cabinets in the medication storage room and the medication refrigerator are checked for expired medication and the findings are documented on the daily audit tool. Registered Nurse #9 stated they checked the Comirnaty COVID-19 Vaccine date daily and thought it had a 2027 expiration date. Registered Nurse #9 further stated that they should have made sure that the vaccine was not expired as it should have been discarded.
On 05/05/2025 at 4:04 PM, Registered Nurse #10, who was the Unit Manager, was interviewed and stated that there is an audit tool that the nurses complete every shift that documents any identified issues with medication storage including expired medications. Registered Nurse #10 also stated that the unit manager is supposed to check the audit tool, the medication storage room and the medication refrigerator room for expired medications. Registered Nurse #10 further stated that they spot checked the medications in the 3rd Floor Medication Storage Room and in the 3rd Floor Medication Refrigerator room [ROOM NUMBER] weeks ago. The Comirnaty COVID-19 Vaccine was stored in the refrigerator, but they did not check the expiration date because the nurses documented on the audit tool that the vaccine was not expired. The vaccine should not have been there if it was not going to be used, and it should have been discarded prior to the expiration date.
On 05/05/2025 at 11:48 AM, The Director of Nursing was interviewed and stated that the staff nurses are responsible for checking that medications and vaccines that are stored on the units are not expired. They should be performing this every shift everyday as part of their rounding responsibility and the unit manager should be overseeing the staff nurses and ensuring that they are reviewing the meds and discarding them appropriately. The Director of Nursing stated this was an oversight, the nurses did not see the vaccine expiration date and therefore the expired vaccine was not discarded.
10 NYCRR 415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident received dental services in a timely manner. This was evident in 1 (Resident #30) of 1 resident reviewed for Dental out of a sample of 38 residents. Specifically, Resident #30's dentures fell on the floor and broke on 03/12/2025. The dentures were not repaired and returned to the resident for 50 days. There was no documentation of circumstances that led to the delay of replacing the resident's dentures.
The findings are:
The facility policy titled Dentures with a last revised date of 07/2019 stated that the facility is responsible for managing residents' dentures. It will be the responsibility of the facility to replace damaged or lost dentures if they are dropped and broken by a staff member. If dentures are damaged or lost, residents will be referred for dental services within 3 days. Documentation will be completed regarding what is being done to ensure the resident is able to eat and drink adequately until seen by the dentist.
Resident #30 had diagnoses that included Chronic Atrial Fibrillation and Cancer.
The Quarterly Minimum Data Set, dated [DATE] documented that Resident #30 was cognitively intact and required setup and cleanup assistance with eating. The Minimum Data Set assessment also documented that Resident #30 had no concerns with swallowing and oral/dental status.
The Nursing Progress Note dated 03/12/2025 documented that Resident #30's dentures were dropped and broke. The doctor was notified and ordered for Resident #30's diet to be downgraded, and for dental and speech consultations to be implemented. The Dentist was contacted and was scheduled to evaluate Resident #30 on 03/17/2025.
The Nursing Progress Note dated 03/17/2025 documented that Resident #30 was not seen by the Dentist.
The Nursing Progress Note dated 03/19/2025 documented that Resident #30 was seen by the Dentist and their dentures were taken for repair. It also documents that The Dentist stated that it would take two weeks for the repaired dentures to be returned to the resident.
The Nursing Progress Note dated 04/12/2025 documented that Registered Nurse #1 reached out to the Dentist and was told that Resident #30's dentures were not repaired yet.
The Speech Therapy Progress Note dated 04/18/2025 documented that Resident #30 was on a ground texture and thin liquid diet but would be able to return to a regular texture diet once their dentures were repaired.
The Dietary Progress Note dated 04/30/2025 documented that Resident #30 had expressed dissatisfaction with the meals they were able to eat on the downgraded diet.
There was no documented evidence in the electronic medical record that Resident #30 was informed that the repair would take more than two weeks, or that the facility contacted the Dentist related to the status of the repair after 04/12/2025.
A rehabilitation referral note dated 05/01/2025 completed by the Director of Nursing documented that Resident #30 received their new dentures today and was being referred to the Speech Language Pathologist to upgrade the diet back to prior level of function.
On 04/29/2025 at 10:52 AM, Resident #30 was interviewed and stated that around two months prior, a Certified Nursing Assistant had accidentally dropped and damaged their dentures. Resident #30 stated that they had been seen by a dentist who stated it would take two weeks for their dentures to be repaired, but they had not received any update from staff on the status of their dentures since then. Resident #30 also stated that they did not wish to be on a downgraded diet any longer and needed their dentures back in order to be able to return to a regular diet.
On 05/01/2025 at 09:46 AM, Certified Nursing Assistant #2 was interviewed and stated that Resident #30's dentures were being repaired by the Dentist. Certified Nursing Assistant #2 further stated that Resident #30 had been downgraded to a soft diet which the resident was not enjoying. Certified Nursing Assistant #2 stated that Registered Nurse #1 was responsible for ensuring the dentures were returned to the resident.
On 05/01/2025 at 10:01 AM, Registered Nurse #1 was interviewed and stated that Resident #30's dentures were damaged in the facility in mid-March 2025. Registered Nurse #1 stated that they had contacted the Dentist to follow up on the status of the denture repair but could not recall when they had last followed up with the Dentist.
On 05/01/2025 at 10:17 AM, the Director of Nursing was interviewed and stated they were not sure why it had taken longer than two weeks for Resident #30's dentures to be repaired. The Director of Nursing stated that it was Registered Nurse #1's responsibility to follow up on things like denture repairs. The Director of Nursing further stated that it was important for Resident #30 to get their dentures back in a timely manner because the lack of dentures was preventing them from being able to consume a regular diet.
On 05/01/2025 at 10:22 AM, the Dentist was interviewed and stated that it typically takes two weeks for dentures to be repaired. The Dentist stated that in this case, Resident #30's denture repair was delayed due to a two-week delay in the dental laboratory picking up the damaged dentures, and then delayed again after the repaired dentures were delivered to the wrong facility. The Dentist described the situation and delays as a mess. The Dentist further stated that they informed Registered Nurse #1 of this, and Registered Nurse #1 should have communicated the delay to Resident #30.
10 NYCRR 415.17 (a-d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey conducted from 04/29/2025 to 05/06/2025, the facility did not ensure that a resident or their representative was afforded the opportunity to participate in their care planning process. This was evident in 1 (Resident #207) of 1 resident reviewed for care planning out of 38 total sampled residents. Specifically, Resident #207's representative was not consistently invited to participate in their care plan meetings.
The findings are:
The facility's policy titled Care Planning - Interdisciplinary Team with a last revised date of 08/2024 documented the resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are invited and encouraged to participate in the development of and revisions to the resident's care plan.
Resident #207 had diagnoses which included Other Sequelae of Cerebral Infarction, Alzheimer's Disease, and Unspecified Dementia.
The Annual Minimum Data Set assessment dated [DATE] documented that Resident #207 was severely impaired in cognition and only the representative participated in the assessment.
On 04/29/2025 at 11:21 AM, Resident #207's designated representative was interviewed and stated they are responsible for making decisions for Resident #207. They stated they had not been invited to any care plan meeting for Resident #207 in 2024.
A care plan meeting schedule documented that care plan meetings for Resident #207 were scheduled on 03/13/2024, 06/12/2024, 09/11/2024, and 12/11/2024.
The social service progress notes dated 09/11/2024 and 12/11/2024 documented Resident #207's representative was in attendance for these care plan meetings.
There was no documented evidence in the medical record that Resident #207 and/or the designated representative were invited to or participated in the quarterly care plan meetings scheduled on 03/13/2024 and 06/12/2024.
On 05/05/2025 at 10:32 AM, Licensed Practical Nurse #4 was interviewed and stated Resident #207 was alert and confused, and that it was their representative who makes the decision for Resident #207.
On 05/05/2025 at 10:54 AM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for scheduling the care plan meetings and emails them to the interdisciplinary team. The Minimum Data Set Coordinator stated it is the social worker's responsibility to invite residents and/or their designated representative to participate in care plan meeting.
On 05/05/2025 at 11:01 AM, Social Worker #1 was interviewed and stated they are the social worker assigned to Resident #207. They stated Resident #207 is cognitively impaired to participate in care plan meetings and had invited their designated representative to care plan meetings. Social Worker #1 stated they reviewed the resident's progress notes and there was no documented evidence that their representative was invited to the care plan meetings on 03/13/2024 and 06/12/2024.
On 05/05/2025 at 11:15 AM, the Administrator was interviewed and stated it is the social worker's responsibility to invite residents and / or their representatives to all care plan meetings and that the invitation must be documented in the progress notes.
10 NYCRR 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews conducted during the recertification survey, the facility did not ensure comprehensive person-centered care plans were developed and implemented for each residents to meet the residents' medical, nursing, and psychosocial needs that were identified in the comprehensive assessment. Specifically, 1.) a comprehensive care plan (CCP) was not developed to address a resident's Foley Catheter; 2.) a CCP was not developed to address a resident's diagnosis of End Stage Renal Disease (ESRD) on Dialysis, and 3.) the facility failed to implement interventions to stabilize or improve nutritional status as identified in the resident comprehensive assessemnt. This was evident for 1 of 1 resident reviewed for Dialysis, 1 of 3 residents reviewed for pressure ulcers, and 1 of 7 residents reviewed for Nutrition out of 38 residents sampled residents (Resident #105, 225 and 361).
The findings are:
The facility policy titled Care Plans-Comprehensive dated 10/2019 documented the following: A comprehensive, person-centered care plan, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also documented that the CCP must be developed within 7 days of completion of required of the comprehensive assessments. The policy further documented that the area of concerns is identified during the resident assessment will be evaluated before interventions are added to the care plan.
1) Resident #225 was admitted to the facility on [DATE] with diagnoses which include Pressure Ulcer, Obstructive Uropathy, and Type 2 Diabetes.
The most recent quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition. The MDS further documented the resident had a Foley Catheter.
On 02/14/22 at 11:55 AM, the resident was observed in bed. A Foley catheter drainage bag concealed with a privacy bag was hanging on the side of the bed.
The physician's order dated 09/23/21 documented the following: Indwelling Urinary Catheter, Size 16 French . Change Catheter monthly and as needed for Obstructive Uropathy. This order was discontinued when the resident transferred to the hospital on [DATE].
The re-admission physician's order dated 12/13/21 documented the following: Indwelling Foley Catheter to Down Drain: Balloon: 15 Fr.:16 Change as Needed.
The Nurses' re-admission note dated 12/13/2021 documented the resident was re-admitted with a 16 Fr Foley Cather in place.
A review of the resident's comprehensive care plan dated 09/23/21, revised 12/13/21, revealed no documented evidence that a care plan was developed for catheter use.
A review of the Certified Nursing Assistant (CNA) Accountability Record dated 09/23/21 to 02/16/22 revealed no documented evidence of catheter care.
On 02/16/22 at 03:00, the Certified Nursing Assistant (CNA #2) was interviewed and stated he/she cared for Resident #225 consistently. CNA #2 stated the resident was admitted with a Foley catheter, and he/she empties the drainage bag and reports any irregularities such as urine ordor or leakage to the nurse. CNA #2 also reported catheter care is documented in the CNA accountability. C.N.A #2 was unable to find the catheter care entries. They concluded by saying I don't have it.
On 02/16/22 at 03:10 PM, the Registered Nurse Supervior (RN#1) was interviewed. RN #1 stated that the RN Supervisor is responsible for developing the care plans and completion of certain assessments. RN #1 stated Resident #225 was admitted with a Foley Catheter, which is still in use. RN #1 stated they could not find a care plan that addressed the resident's catheter in the medical record. They stated that he was not here at the time the care plan was develpoed.
On 02/16/22 at 03:25 PM, the Director of Nursing (DON) was interviewed. The DON stated that when the resident is admitted to the facility, the nurse assigned to the unit is responsible for the care plans. The IDT are responsible for the Comprehensive care plans from admission, readmission or when there is a significant change in resident status. The DON stated that nursing is responsible for catheter care, and no catheter care plan was developed for Resident #225. The DON also stated that the catheter care should also be included on the C.N.A accountability. The DON stated care planning has not been brought to QA or addressed in daily morning report as a concern. The DON stated it was an oversight.
2) Resident #361 was admitted to the facility on [DATE] with diagnoses which include Dementia, Hip Fractures, Depression, and Malnutrition.
The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident's had intact cognition with a Brief Interview of Mental Status Score of 13 out of 15. The MDS also documented that the resident required an extensive assistance with one person when performing Activity of Daily Livings (ADLS).Please use more specific MDS info. Things that would be related to nutrition and weight loss specifically from the MDS. This is too general. There was none. No weight loss
The resident's Nutrition Comprehensive Care Plan (CCP) dated 01/06/22 documented that the resident's goal was to maintain weight with no significant changes; note resident on diuretic treatment therefore weight fluctuations anticipated secondary to fluid shifts. Resident was at risk for malnutrition per the Minimum Nutritional Assessment (MNA) score. Estimated nutritional needs for nutritional adequacy and weight stability stated above. what were the nutritional needs? desired body weight range? Interventions include provide diet plan as ordered, monitor weight as ordered. Report significant/pattern of changes in weight to Dietitian and MD. Resident will maintain weight without significant gain or loss through the review date.
A review of the resident's weight records on 02/11/22 revealed that the resident was weighed 2 times since admission.
01/6/2022: 139.6 lbs
02/7/2022:135.8 lbs
A review of all progress notes dated from 01/03/22 to 02/11/22 revealed that was no documented evidence that the resident received weekly weights as ordered by the physician.
On 02/11/22 at 12:56 PM an interview was conducted with the Certified Nursing assistant (CNA #1), who has been assigned to the resident since admission on the 7AM to 3PM shift. CNA #1 stated that the RN supervisor will informs staff which residents they need to weigh daily from the shower list. The weight is then verbally reported to the nurse.
On 02/15/22 at 03:37 PM, CNA #2 was interviewed. CNA #2 stated the nurse informs the CNAs regarding which residents need a weight taken daily. Sometimes the unit has substitute staff, and they were not consistent with the resident weight plan.
On 02/15/22 at 03:03 PM, an interview conducted with the DON stated that the weight is monitor following a day of admission because we assume that the residents might be tired when getting here. She stated that weight is monitored weekly for 4 weeks , then monthly. There are cases like Congestive Heart Failure (CHF) and we may weight resident on a daily basis depending on the resident conditions. The DON also stated that at the start of the shift , the nurse will tell the CNA who are to be weighed today, the challenge there is that we have some temporary staff as well who don't know our schedules. Sometimes resident refused weight and they forget to document or inform the nurse on the unit. The DON stated they go over the morning reports about the residents that are losing weight and the dietician, and the nurse do communicate with each other. The DON could not explain why the resident did not have any documentation of the weight record .
On 02/16/22 11:14 AM, an interview conducts with Chief Clinical Dietician, stated that he had been working here since April of 2021, and provide oversight for other dieticians and supervisors them. The chief stated that If resident is admitted , we weight the resident on admission, collect diet history, food preferences, care plans and the MDS are completed thereafter. They stated that the residents are weight on the next day of admission and weekly for 4 weeks and then monthly, depending on the situations. The nursing gives directive for nursing on who need to be weighed. The RD stated that the dietary dept. doesn't provide list for residents who needed to be weighed. They stated they get alert on the electronic medical record (EMR) on weight change, or the nursing will let us know if a weight change. They also stated that the order will change to weekly order if there is a need for a weekly weight. The nurse and the physician are responsible for the order to be carried out and at the same time we do communicate with them. They stated that there were no concerns in the dietary dept that is lingering. As for Resident #361, they stated that the weight is stable, and that they understand the weight was not being monitored as ordered, and he/she believes it was an oversight.
3) Resident #105 was admitted to the facility with diagnoses of chronic kidney disease stage 5, End Stage Renal Disease (ESRD) with dependence on dialysis, and fracture of the right pelvis.
The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #105 had impaired cognition with active diagnoses of ESRD, dependence on renal dialysis, and coronary artery disease. It further documented Resident #105 required extensive assistance with one-person physical assistance for transfer and toilet use and received dialysis treatment.
Hospital Discharge summary dated [DATE] documented the resident had ESRD and was on hemodialysis MWF via Right (R) Permacath (PC).
The Physician's Order dated 11/18/21 documented the following: please arrange transportation and schedule dialysis appointment every Monday, Wednesday, and Friday. Preferably 12 Noon or 3 PM.
The Physician admission Note dated late entry on 11/29/21documented admitting diagnoses of dementia and ESRD on hemodialysis MWF via R PC with plans to monitor vitals and weights.
On 2/10/22 at 3:38 PM, a review of resident's medical record revealed there was no documented evidence of CCP developed for dialysis treatment.
On 2/14/22 at 1:10 PM, Registered Nurse Manager (RN #7) was interviewed. RN #7 was asked about resident's CCP, RN #7 stated it was an oversight and that CCP related to dialysis treatment was initiated on 2/11/22.
On 2/16/22 at 12:26 PM, the Director of Nursing (DON) was interviewed. DON stated the admission nurse will implement care plans upon admission, and the unit nurse manager is also responsible to initiate and/or revise the CCP according to the resident's plan of care.
415.11 (c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure that a resident's comprehensive care plan for hospice was reviewed and revised. This was evident for one of 38 sampled residents (Resident #5).
The findings are:
The Care Plan policy last reviewed in October 2019, documented that care plans must be reviewed and modified as needed. The IDT team reviews and update the care plan at least quarterly, with scheduled quarterly MDS assessments.
Resident #5 was admitted with diagnoses which include Gastroesopogeal Reflux Disease (GERD), renal insufficiency, and hyperlipidemia.
The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident required the extensive assistance of two persons for for bed mobility, transfer, bathing, and toileting. The MDS documented the resident is receiving hospice.
The current Doctor's order documented the resident is on hospice. The order was initiated 2/11/2020.
The comprehensive care plan (CCP) for hospice documented that the care plan was initially developed on 2/11/20. There was no documented evidence that the hospice care plan was ever reviewed and revised quarterly since it was initiated.
On 02/15/22 at 12:11 PM, the Registered Nurse (RN #3) stated that the resident has been on hospice since February 2020. RN #3 stated care plans are supposed to be reviewed quarterly and annually, and Resident #5's hospice care plan should have been reviewed at least once every 3 months. RN# 3 further stated that the facility has a new Electronic Medical Record (EMR) program, and somehow, the care plans were not carried over to the new system. RN #3 further stated that it was an oversight.
On 02/15/22 at 12:23 PM, the Registered Nurse Unit Manager (RN #4) stated he/she is responsible for all nursing staff and residents on the unit. RN #4 stated that he/she or the charge nurse is responsible for developing and updating the care plan. The hospice care plan should have been reviewed and revised. Care plans should be reviewed at least quarterly.
On 02/16/22 12:30 PM, the DON stated that care plans are supposed to be updated as needed as staff sees changes in conditions. The nurse manager or charge nurse works with the social worker to develop the hospice care plans. The care plan should be reviewed at least quarterly, and the resident's hospice care plan should have been reviewed quarterly.
415.11(a)(4)

Based on observation, interviews and record review conducted during the Recertification Survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, 1) residents complained of low staffing levels; 2) an incident of resident to resident abuse occurred when the unit was below Par in staffing and care planned supervision was not provided to the residents (F600); 3) in January 2022 the facility was found to have staffed all unit to its designated par levels on only 4 of 31 days.
The findings are:
1) On 02/10/2022, a meeting was held with members of the Resident Council. When asked whether they got the help and care they needed without waiting a long time, Resident #23 said, Never. On 6 we had only 2 aides. Resident #40 stated that there were only 2 aides on their unit, the 10th floor, until the surveyors came and now there were 4. Resident #122 said, It's hardest at night. It's too often we hear, 'I'm the only one on the floor.'
Resident Council meeting minutes were reviewed starting August 2021 and revealed that at the August 5th meeting, a resident on the 5th floor stated they needed help on the evening shift during the weekend of July 31 and was told that there were only 2 CNAs on staff and both were going to lunch at the same time. During a meeting on October 7, 2021, multiple residents on the 5th floor complained of the ratio of CNAs to residents on the unit, the decline in residents getting out of bed during the day and the unit being understaffed at night. The same complaint was made the following month, on November 15, 2021. On 11/15/2021, the 5th floor Nurse Manager made a written reply to their complaint, stating to have met with the unit staff and reinforced the importance of providing help promptly, answering call bells and attending to the residents' needs, providing showers and getting the residents out of bed. The Nurse Manager noted that the staff to resident ratio was 1:9 with 4 CNAs on the unit during the day shift.
2) Please refer to findings at F600 for the incident of Resident to resident abuse. The second incident for Resident #295 and Resident #97 occurred when there was no one available to monitor the hallway. There were 3 CNAs on the unit at the time instead of 4.
3) The Facility Assessment was reviewed and revealed that each unit would be staffed according to its acuity level and staffing would be re-evaluated regularly.
On 02/16/2022, the facility's Par Level Form was reviewed and revealed that the facility considered 4 CNAs to be par on all units for the day shift, 3 CNAs par for the evening shift and 2 CNAs for the night shift.
On 02/16/2022, unit staffing sheets were reviewed for January 2022 day shift. Each unit was full or had 1 empty bed, and revealed the following:
On 01/01/2022, 9 units had 3 CNAs and 3 units had 2 CNAs
On 01/02/2022, all units had 2 CNAs
On 01/03/2022, all units had 3 CNAs
On 01/04/2022, 2 units were fully staffed to par level, 10 units had 3 CNAs
On 01/05/2022, 5 units were fully staffed to par level, 7 units had 3 CNAs
On 01/06/2022, 4 units were fully staffed to par level, 8 units had 3 CNAs
On 01/07/2022, 4 units had 3 CNAs, 8 units had 2 CNAs
On 01/08/2022, 11 units had 3 CNAs, 1 unit had 2 CNAs
On 01/09/2022, 6 units had 3 CNAs, 6 units had 2 CNAs
On 01/10/2022, 6 units had 3 CNAs, 6 units had 2 CNAs
On 01/11/2022, 1 unit was fully staffed to par level, 11 units had 3 CNAs
On 01/12/2022, all units were fully staffed to par levels
On 01/13/2022, 6 units were fully staffed to par level, 6 units had 3 CNAs
On 01/14/2022, 3 units were fully staffed to par level, 9 units had 3 CNAs
On 01/15/2022, 11 units had 3 CNAs, 1 unit had 2 CNAs
On 01/16/2022, 10 units had 3 CNAs, 2 units had 2 CNAs
On 01/17/2022, 9 units were fully staffed to par level, 3 units had 3 CNAs
On 01/18/2022, 7 units were fully staff to par level, 5 units had 3 CNAs
On 01/19/2022, 2 units had 5 CNAs, 9 units had 4 CNAs and 1 unit had 3 CNAs
On 01/20/2022, 5 units were fully staffed to par level, 7 units had 3 CNAs
On 01/21/2022, 5 units were fully staffed to par level, 7 units had 3 CNAs
On 01/22/2022, 5 units were fully staffed to par level, 7 units had 3 CNAs
On 01/23/2022, 1 unit was fully staffed to par level, 7 units had 3 CNAs and 4 units had 2 CNAs
On 01/24/2022, 9 units were fully staffed to par level, 3 units had 3 CNAs
On 01/25/2022, 9 units were fully staffed to par level, 3 units had 3 CNAs
On 01/26/2022, 5 units had 5 CNAs, 7 units were fully staffed to par level
On 01/27/2022, 6 units had 5 CNAs, 6 units were fully staffed to par level
On 01/28/2022, 10 units were fully staffed to par level, 2 units had 3 CNAs
On 01/29/2022, 2 units were fully staffed to par level, 8 units had 3 CNAs and 2 units had 2 CNAs
On 01/30/2022, 8 units had 3 CNAs, 4 units had 2 CNAs
On 01/31/2022, 4 units were fully staffed to par level, 8 units had 3 CNAs.
As per this table, the facility was fully staffed to par level on only 4 of 31 days during January 2022.
On 02/11/2022 at 11:52 AM, CNA #10 was interviewed on the 6th floor and stated to work in the facility on some weekends and that it was not uncommon to have only 2 CNAs on the unit during the day shift. The CNA stated, We usually miss lunch then, but we cannot punish the residents because there is not enough staff, and noted that the unit does not work this short every weekend but that even with 3 CNAs assigned, each CNA had to handle 12 residents, many of whom were heavy care or needed 2 assists for care, so some of those residents would not be gotten out of bed unless they asked but would be made comfortable in bed instead.
On 02/15/2022 at 10:21 AM, RN #6 was interviewed on the 6th floor and stated that usually there were 3 CNAs on the day shift but when one of them called out there would be only 2. If those CNAs were regulars on the unit the shift still ran smoothly, but if one was a floater, the nurse had to follow that CNA to keep them updated and help them prioritize because they didn't know the residents. Sometimes the nurse would assign themself to the unit day room to supervise the residents, but they were also trying to give medications at the same time. The RN stated, It's really hard. Even with 3 CNAs it's really hard. Some residents do get left in bed.
On 02/15/2022 at 10:51 AM, CNA #11 on the 6th floor was interviewed and stated, Oh, God, I can't explain, it's a nightmare. When there are only 2 CNAs you have to do 18 total care people here and 99 percent of the time on weekends, it's only 2. The CNA stated to have worked in the facility for 16 years and said it was embarrassing to them that when family members phoned the unit, they will call ten times in a day and their residents are still in bed, and they are concerned, but I can't take 18 people out of bed when there are only 2 staff, it's impossible.
On 02/26/2022 at 9:01 AM, the Staffing Coordinator was interviewed and stated to have been working in the facility in the capacity of Staffing Coordinator since December 2021 only. They stated that staffing needs are re-evaluated daily and that staff are reminded to call out no later than 5:00 AM for the day shirt and 1:00 PM for the evening shift so that replacements can be found. Staffing was an issue throughout the healthcare industry and the facility had increased the number of agencies it used to obtain fill-in staff and continued to seek to hire permanent staff.
On 02/16/2022 at 9:26 AM, the Director of Nursing was interviewed and stated that staffing was the same on weekdays and on weekends but that it was a challenge in general. The staffing ratios were only as good as those staff members actually showing up to work. However, the nursing supervisors would try to modify certain staff assignments and float staff from other units to fill in gaps if needed. For a staff member to say they could not take a resident out of bed due to short staffing would be inappropriate because that staff member should have come to Nursing Administration which would look at the bigger picture for them.
On 02/16/2022 at 3:18 PM, the Assistant Director of Nursing was interviewed and stated that the facility has added to the agencies it looks to for staffing, from 2 to now 7, and continues to expand its reach in accessing staff to man each shift. CNA recruitment efforts are ongoing. The facility has been trying to get existing staff to pick up extra shifts by offering incentives and is also offering cash bonuses to staff members who refer their friends for employment. The facility has not called the DOH Staffing Hotline to date. In December 2021 and January 2022 about 60 new staff were hired, and staff orientation sessions had in excess of 20-25 people. There were still issues with staff retention and retirement, and the facility was in competition with hospitals for staff.
415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #288 was admitted to the facility on [DATE] with diagnoses which include Major Depressive Disorder, Hypertension, and Chronic Atrial Fibrillation.
The Minimum Data Set (MDS) assessment dated [DATE] identified resident # 288 cognition as intact with a Brief Interview for Mental Status score of 14.
A Pharmacy Consultant Note dated 08/31/2021 at 12:54 PM documented to see consultation note for any noted irregularities and recommendation.
A Medication Regimen Review dated 08/31/2021 documented that Resident # 288 is on Protonix, long term. Usage greater than eight weeks is not generally recommended due to the potential for C-diff, bone loss, fractures, and pneumonia. Please evaluate the risk/benefits of continuing the use of this medication.
A review of a Medication Regimen Review dated 08/31/2021 revealed that the attending physician signed the recommendation on 02/13/2022.
During an interview on 02/15/2022 at 10:21 AM, the Attending Physician (AP) said that reviewing the drug regimen recommendation does not take long. The medication regimen review report dated 08/31/2021 was signed off a couple of days ago because the AP was not aware of the report.
During an interview on 02/16/2022 at 12:09 PM, the Director of Nursing stated that the Pharmacist does the drug regimen review and sent them the report. The report is distributed to the medical record and then forwarded to the medical staff. Nursing reviews the nursing issues, and the attending physician reviews the medical issues. The attending physician is supposed to review the recommendation within 30 days unless it is urgent.
During an interview on 02/16/22 at 11:52 AM, the Administrator said that the medication regimen review report goes to nursing, medical, and recently to the Administrator. The physician reviews it and responds to the recommendation. The attending physician should review the recommendation, and it should be swifter than a month. The attending physician is on the email and receives the report immediately. Two to three months is way too long for an attending physician to review a pharmacy consultant recommendation.
10NYCRR415.18(c)(2)
Based on record review and staff interviews conducted during the Recertification and Abbreviated survey, the facility did not ensure that irregularities identified by the pharmacist and forwarded to the facility were acted upon. Specifically, the facility failed to document in the resident's medical record that irregularities identified by the consultant pharmacist had been reviewed and what, if any, action has been taken to address the issues. This was evident for 2 out of 5 residents reviewed for Unnecessary Medications out of a sample of 38 residents. (Resident # 215 and Resident #288).
The findings are:
The facility policy Pharmacy Consultant Med Review dated 4/2018 and last reviewed on 3/2020, documented that the facility shall employ and maintain the services of a licensed pharmacist (Pharmacy consultant), who shall review the medication regimen review (MRR) of each resident at least monthly and more frequently, as needed. The primary purpose of this review is to assist the facility, maintain each resident's highest practicable level of functioning and quality of life, by helping them utilized medications appropriately and prevent or minimized adverse consequences related to medication therapy to the extent possible. The Director of Nursing (DON) will notify the facility's medical director if the resident physician does not follow through on the consultant's recommendations.
1) Resident #215 was admitted to the facility on [DATE] with diagnosis that includes Dementia with behavioral disturbance, psychotic disorder with delusions due to known physiological condition, Alzheimer's Disease, and Major Depressive Disorder.
The Quarterly Minimum Data Set (MDS, a resident assessment tool), dated 12/18/2021 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determined attention, orientation, and ability to recall information) score of 07/15 with severe cognitive impairment. The resident is needing extensive assist with one person assist for bed mobility, transfer, locomotion in unit, dressing, eating and personal hygiene. The resident has also received antipsychotic and antidepressant medication with seven days a week.
The Comprehensive Care Plan (CCP) for uses of psychotropic medications related to diagnoses of psychotic disorder with delusion and depression dated 10/27/2021. Intervention included giving medications ordered by physician. Monitoring/documenting side effects and effectiveness, monitoring or recording occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol.
Physician's order dated 10/22/21 documented that the resident was prescribed Quetiapine Fumarate Tablet 25 mg, give 1 tablet by mouth at bedtime for depressive disorder.
On 10/26/21, the Medication Regimen Review documented (MRR) documented Findings / recommendations documented On Remeron, Quetiapine. As per CMS regulations please evaluate for effectiveness, adverse effects, and gradual dose reduction. The physician responded dated on 2/13/22.
On 12/30/21, the Medication Regimen Review documented (MRR) documented Findings / recommendations documented 12/21 Psych consult addresses Resident on Quetiapine for Diagnosis of depression. Quetiapine is ordered for psychotic disorder with delusion as per MD order. Please evaluate discrepancy. The physician response was dated on 2/13/21.
On 2/16/22 at 11:15 AM, an interview with the primary care physician (PCP) was conducted. PCP stated that there have been so many things assigned to him/her and lately and he/she assumed the MRR was taken care of by the form physician. The PCP stated that he/she had not signed any of the MRRs for a couple of months until last weekend when it was brought to his/her attention. The MRR should be responded to within 30 days. The facility has a medical staffing transition, and the changes have been overwhelming for all of us physicians.
On 2/16/22 at 11:15 AM, an interview with the Facility Pharmacist Supervisor (FPS) was conducted. FPS stated that the assigned pharmacist performs medication review regimen monthly and two to three days after admission or readmission. The pharmacist comes back monthly and continues to write medication regimen review for the nursing and medical department to review. The FPS added that the pharmacist team notified him that there was an issue, as the facility medical and nursing staff had not reviewed the MRR recommendations. Around December 2021, the FPS had a meeting with the Administrator and Medical Director to discuss the lack of response to the MRR. The FPS stated that the facility had a lot of changes in staffing with new owership and the change in medical director, creating delays with the physicians reviewing the MRRs.
On 2/16/22 at 11:05 AM, an interview with the Medical Director (MD) was conducted. The MD stated that he/she is new, and the Director of Nursing (DON) receives the MRR and will review MRR with the physicians. MD added that he/she believes that there are no set timeframe for reviewing the MRR, and the DON will schedule the meeting and notify the physicians. As per MD, there has been a lack of physicians in the facility, and the facility's Nurse Practitioner is out of country. As the Medical Director, he/she handles the urgent issues that need a response within 24 hours, and the primary physicians are assigned to handle the MRR. The MRR should be tracked down monthly. The MD stated he/she did not know why no one has brought this matter to him/her. The MRR is not an urgent matter. The MD stated the facility is in a crisis mode, and there are many other things that are more urgent that require his/her attention, and unfortunately, this is not one of them.
On 2/16/22 at 12:15 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that the pharmacy sends their MRR to both nursing and medical department and both departments review the report. We do respond to agree or not agree. The DON stated he/she thought the medical department was reviewing and responding all the MRRs within 30 days as required. The assigned physician is responsible for signing and responding the MRR. The DON stated no one has brought this issue to him/her until this weekend.
On 2/16/22 at 12:37 PM, an interview with the Administrator was conducted. The Administrator stated that he/she is currently new, and the pharmacy does the MRR monthly. Around December 2021, the pharmacist consultant supervisor met with the Medical Director and has advised the facility that MRRs have not been responded to timely. The Medical Director acknowledged the issue and stated that he/she will be reviewing the MRR. The Administrator added that he/she thought the MRR was taken care, and the MRR should be reviewed monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview conducted during the recertification survey, the facility did not ensure drugs and biological's were labeled in accordance with currently accepted professional principles and stored under proper temperature controls per manufacturer's recommendations. Specifically, four opened insulin pens were not dated with dates they started using them. This was evident for 1 of 8 carts observed out of 12 units reviewed for Medication Storage (Unit 7th).
Findings are:
The facility policy titled Medication Storage dated 01/2019 documented the following: The facility will store medications in a manner that maintains the integrity of the product, ensure the safety of the residents, and in accordance with Department of health guidelines.
As per the manufacturer recommendations, documented on the insulin package inserts, documented the following: 1.) Throw away opened Levemir insulin 42 days after opening, even if insulin still left in them. 2.)Throw away open Novolog insulin 28 days after opening, even if insulin still left in them. 3.) Throw away opened Humalog insulin 28 days after opening, even if insulin still left in them.
On [DATE] at 11:32 AM, during the medication storage observation at unit 7, the following insulins were observed with the LPN#1. Undated Novolog flex pen, undated Levemir flex pen, and 2 undated Humalog flex pens. All were observed on the top drawers of the medication cart.
On [DATE] at 11:36, the LPN # 1 was immediately interviewed. They stated that the insulin supposed to be dated when opened to enable them know exactly when to discard the insulin. They stated that the facility sometimes have some agency staff and they do not follow the facility protocol about medication storage and labeling. The LPN #1 also stated that they never checked the insulin in recent days because they were busy. They concluded by saying that all opened insulins supposed to be discarded within 28 days.
On [DATE] 11:49 AM an interview conducted with the RN #1 supervisor who stated that the if insulins is not used and has to be stored and if it is used it has to be dated from when they are opened. the insulin has to be dated 28 days after the insulin was open. He stated those insulin suppose to the thrown away and we ordered another insulins and we . we already inservice staff regarding labeling. i believe if was Levemir has to be thrown out in 42 days. He also stated that every insulin pen or vial has to be personalized. must have a resident name on it. for the insulin with no name. i cant ex[lain whey insulins did not have a name.
On [DATE] 03:14 PM an interview conducted with the DON who stated that the insulin suppose to be dated when open so that we can know how long to discord the insulin. If insulin are not dated, no way we can track them. Each resident must have their own insulin and if the resident discharged from the facility, we discard them or give to them . The DON stated that the pen come from pharmacy and the moment they start using insulin and they must date it. she stated that every single nurses supervisor are responsible to ensure that the rooms are free from expired meds.
415.18(e)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that a baseline care plan for each resident that includes the instructions needed to provide effective, person-centered care of the resident was developed and implemented and provide the resident and their representative with a written summary of the baseline care plan. Specifically, Baseline Care Plans were initiated but not completed within 48 hours of admission, and residents and their representatives were not provided with a written summary of the baseline care plan. This was evident for 1 of 7 residents reviewed for Nutrition, and 1 of 5 residents reviewed for Unecessary Medicatiosn out of 38 sampled residents. (Residents #312 and 361).
Findings are:
The facility policy titled Care Plans-Baseline dated 01/2020 documented that the facility develops a Baseline Care Plan within 48 hours based on initial admission. The policy also documented that the Interdisciplinary Team (IDT) will review the healthcare practitioner's order and implement a Baseline Care plan to meet the resident's immediate care needs, including but not limited to: Physician order, Dietary orders, Therapy Services, Social Services and Pre-admission Screening and Resident Review (PASRR) recommendation, if applicable.
1) Resident #312 was admitted to the facility on [DATE] with diagnoses which include Hypertension, Diabetes, and Dementia.
The quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident cognitive status is impaired. The MDS also documented that the resident required extensive assistance of one person when performing Activity of Daily Living (ADLS).
On 02/11/22, the Baseline Care Plan (BCP), created on 12/27/21, had a status of incomplete. There was no documented evidence that the BCP was signed and provided to the resident and/or designated representative.
2) Resident #361 was admitted to the facility on [DATE] with diagnoses which include Dementia, Hip Fractures, and Depression.
The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident required extensive assistance of one person when performing Activity of Daily Livings (ADLS).
On 02/11/21, the Baseline Care Plan (BCP), created on 01/03/22 had a status of incomplete. There was no documented evidence that the BCP was signed and provided to the resident and designated representative.
The facility did not develop Baseline Care Plans within 48 hours after the residents were admitted to the facility.
On 02/11/22 at 12:37 PM, the Registered Nurse (RN#1) was interviewed. RN #1 stated that the Baseline Care Plans (BCP) are initiated immediately upon admission. RN #1 stated the nurse should ensure that the BCP is completed within 48 hours of admission. The RN assigned to the unit is responsible for the BCP and any ongoing care planning. RN #1 also stated that the BCP involves the Interdisciplinary Team (IDT), which includes the dietary, nursing, rehab and social services departments. RN #1 stated once the BCP is completed, a meeting is held with the resident and their representative. The RN could not explain the reason why the BCP was not completed.
On 02/15/22 at 02:50 PM, the Director of Nursing (DON) was interviewed. DON stated that when the resident is admitted to the facility, the nurse assigned to the unit is responsible for the care plans. The RN will initiate the BCP and ensure all the IDT are met and complete the BCP within 48 hours. They stated multiple disciplines are responsible for the care plans, such as Nursing, Rehab, Activity, Nutrition. They stated that they haven't seen any issues like care plan issues at the QA meeting. She also stated that the software can show them update on what is due and what needed to be updated but I guess that was not being overserved. The DON concluded by saying that the assessments were completed; just that they were not locked because maybe they were waiting for some information, and by the time they went back, it was already late.
On 02/16/22 at 11:38 AM, an interview was conducted with the Chief Clinical Dietician. He/She stated that the dietary department is also responsible for completing the nutritional section of the Baseline Care Plan however, they are not responsible for locking the record for final completion. Nursing is responsible for making sure the BCP is submitted within 48 hours. The Director of Clinical Services concluded by saying that they were never aware of care plan issues, and it was never reported to them at daily morning meeting.
On 02/16/22 at 11:59 AM, an interview was conducted with the Director of Social Work (DSW). The DSW stated nursing is primarily responsible for ensuring the BCP is completed within 48 hours, but Social Work can assist if needed. The DSW stated Social Services does not provide the resident or family representative with a copy of the BCP; the nursing unit supervisor provides the copy.
On 02/16/22 at 12:11 PM, an interview was conducted with the Director of Rehab. He/she stated that the rehab dept is responsible for completing the rehab portion of the baseline care plan within 48 hours. He/she stated that once the resident is admitted , rehab sees the resient within 24 hours to complete the rehab assessment and endorse to nursing and the social worker.
[10 NYCRR 415.11]