Every finding on record at Adira At Riverside Rehabilitation and Nursing

Based on observations, interviews, and record review conducted during the abbreviated survey, the facility did not ensure residents received quality care for two (2) (Residents #1 and #6) of five (5) residents reviewed for pressure ulcers. Specifically, 1) Resident #6 was ordered to receive wound treatment more frequently than recommended by the wound care specialist, 2) wound care specialist findings and recommendations for Resident #1 were not accurately transcribed and signs of worsening infection were not thoroughly reviewed and addressed.The findings are:1) Resident #6 had diagnoses of chronic respiratory failure with ventilator dependence and cerebral infarction.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #6 was severely cognitively impaired and totally dependent on staff to perform activities of daily living. Resident #6 had three unhealed pressure ulcers present on admission to the facility and one unhealed facility-acquired pressure ulcer.The Nursing Note dated 03/23/2026 documented Resident #6 was readmitted from the hospital after receiving a blood transfusion for anemia and had sacral, right mid-back, right buttock, and left lateral leg pressure ulcers.The Physician Orders transcribed by Registered Nurse #7 dated 03/23/2026 documented Resident #6 was ordered treatment to their right mid-back and right lateral buttock daily and as needed. Resident #6's right medial buttock, sacral, and left lower leg ulcers were ordered treatment twice daily and as needed.The Wound Note dated 03/27/2026 documented Wound Physician Assistant #1 ordered treatments be administered daily and as needed to Resident #6's right mid-back, sacral, right medial buttock, right lateral buttock and left lateral leg ulcers.Physician Orders transcribed by Wound Nurse #2 dated 03/27/2026 documented treatment orders for Resident #6's mid-back and left lateral leg twice daily and sacral, right medial buttock, and right lateral buttock three times daily. The Treatment Administration Record for 03/2026 documented Resident #6 received treatment to their left lower leg and mid-back twice daily and sacral, right medial buttock, and right lateral buttock three times daily in accordance with Physician Orders from 03/27/2026 until 04/03/2026. On 03/31/2026 at 11:19 AM and 2:35 PM, Wound Care Nurse #2 was interviewed and stated Resident #6 had wounds to the right inferior mid-back, sacrum, right lateral buttock, middle buttock, and left lateral leg. Resident #6's right buttock wound had purulent discharge and showed signs of infection. Wound Care Nurse #2 stated the wound care specialist verbally recommended treatment orders during weekly wound rounds, and they transcribe the treatment orders and recommendations onto the Physica Orders and updated the resident's care plan. Wound Care Nurse #2 stated Resident #6 had wounds with excessive drainage, and their treatment orders were twice daily last Friday, 03/31/2026, when Wound Care Nurse #2 stated they changed Resident #6's treatment orders to three times daily because they noted the resident still had excessive drainage from their ulcers. Wound Care Nurse #2 stated Resident #6 has had excessive drainage for at least a week.On 04/03/2026 at 11:34 AM, Wound Physician Assistant #1 was interviewed and stated they did not give recommendations for Resident #6 to receive treatment more than once daily. Resident #6 had pressure ulcers with chronic infections and Wound Physician Assistant #1 stated they were not aware Resident #6 had excessive drainage and would have recommended Resident #6 be hospitalized if they knew the resident required wound care more than once daily. Wound Physician Assistant #1 stated they assessed Resident #6 today during wound rounds and recommended the resident be hospitalized .2) Resident #1 had diagnoses of chronic respiratory failure with ventilator dependence and hypoxic ischemic encephalopathy.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #1 was severely cognitively impaired, totally dependent on staff to perform activities of daily living and had unhealed facility-acquired stage two and three pressure ulcers.Resident #1's Lab Results dated 12/05/2025 documented Resident #1 had an elevated white blood cell count at 12.79 cubic microliters with a normal reference range of 3.98 to 10.04 cubic microliters.Resident #1's Lab Results dated 12/08/2025 documented Resident #1's white blood cell count increased to 16.13 cubic microliters.The Nurse Practitioner #1 Note dated 12/09/2025 documented Resident #1 had an elevated white blood cell count and infected right buttock ulcer. The note documented Resident #1 would be ordered Zosyn, an intravenous antibiotic, and the wound care team would follow up. d unhealed facility-acquired stage two and three pressure ulcers.The Physician Order dated 12/09/2025 documented Resident #1 was ordered a urinalysis, urine culture, and intravenous Zosyn every eight hours for seven days.A Nurse Practitioner Note dated 12/13/2025 documented Resident #1 did not have a urinary tract infection according to their urinalysis results from 12/10/2025 and Zosyn was discontinued on day four of seven before being completed. The Wound Note by Wound Physician Assistant #3 dated 12/24/2025 documented a wound order for Silvadene to Resident #1's right buttock ulcer. The Nursing Note written by Wound Nurse #2 dated 12/24/2025 documented Wound Physician Assistant #3 evaluated Resident #1 and changed the right buttock treatment to Santyl ointment.The Physician Order transcribed by Wound Nurse #2 dated 12/24/2025 documented Resident #1's right buttock treatment was changed to Santyl ointment. Lab Results dated 12/24/2025 documented Resident #1's white blood cell count increased to 20.63 cubic microliters.The Nursing Note dated 12/25/2025 documented Resident #1 required a blood transfusion due to low hemoglobin values and was transferred to the hospital. The Hospital Discharge summary dated [DATE] in the resident's electronic medical record documented Resident #1 presented in the emergency room for evaluation of severe anemia. Labs drawn at the hospital on [DATE] documented Resident #1's white blood cell count had increased to over 23.00 cubic microliters. A wound culture from 12/25/2025 reported Resident #1 had klebsiella pneumoniae, proteus mirabilis, Acinetobacter, yeast, and staphylococcus organisms present in their wounds. Resident #1 was ordered and began receiving a treatment course of intravenous antibiotics. The hospital attempted and were unsuccessful in obtaining more information from the facility nursing staff related to Resident #1's change in condition prior to hospitalization.On 04/03/2026 at 12:09 PM, Wound Care Nurse #2 was interviewed and stated they performed treatments daily for all ventilator-dependent residents with pressure ulcers. Wound Care Nurse #2 stated they also made rounds with the wound care specialists every Friday. Wound Care Nurse #2 stated they transcribed the wound care specialist orders by taking exactly what was written in the wound consults under Wound Orders and inputting it into the facility's Physician Orders for the medical doctor to sign off. Wound Care Nurse #2 stated they began to provide ordered treatments to residents on the ventilator unit and any issues related to Resident #1 in December 2025 would have to be deferred to the Nursing Supervisor or the Registered Nurse #4. Wound Care Nurse #2 stated they signed the Treatment Administration Record when providing wound care but does not document any assessment or description of residents' wounds. The Wound care specialist does the assessment and documents the measurements and characteristics.On 04/03/2026 at 1:15 PM, the Director of Nursing was interviewed and stated they did not recall any concerns with Resident #1's hospitalization in 12/2025 and did not receive any reports from the admitting nursing staff that the hospital paperwork documented any concerns such as infected purulent wounds or a moldy feeding tube. The nursing staff are responsible for documenting the characteristics of a resident's wound daily during/after treatment. Any changes in the wound should be referred to the medical doctor.On 04/09/2026 at 11:49 AM, Nurse Practitioner #1 was interviewed and stated they sometimes cover episodic concerns on the ventilator unit. The facility has three nurse practitioners available to address concerns on the ventilator unit and coverage is dependent on who is available. The wound care specialists are responsible for evaluating a resident's wounds, addressing stagnant unhealing wounds, and ordering wound treatments.On 04/10/2026 at 10:23 AM, a telephone interview was conducted with the Pulmonologist who stated they were only responsible for the respiratory care of the ventilator dependent residents. The Pulmonologist stated they were not the primary care physician for any of the residents in the facility and were not responsible for ordering treatments or anything else unrelated to a resident's respiratory condition.10 NYCRR 415.12

Based on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure residents with pressure ulcers received treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing in two (Residents #1 and #3) of five residents reviewed for pressure ulcers. Specifically, there was no documented evidence Resident #1's treatment plan was revised to address stagnant wound progress and serosanguinous ulcer drainage for multiple weeks, and 2) Resident #3 was admitted to the facility at risk for skin breakdown and there was no documented evidence they received devices and repositioning to prevent the development of six new pressure injuries.The findings are:The facility policy titled Pressure Ulcer Policy dated 08/30/2024 documented each resident will be assessed for risk factors on admission and for four consecutive weeks. Care plans will be developed with specific interventions based on the resident's risk factors and needs.1) Resident #1 had diagnoses of chronic respiratory failure with ventilator dependence and hypoxic ischemic encephalopathy.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #1 was severely cognitively impaired, totally dependent on staff to perform activities of daily living and had unhealed facility-acquired stage two and three pressure ulcers.The Comprehensive Care Plan related to potential for skin breakdown was created 06/29/2021 and documented Resident #1 had a history of pressure ulcers and impaired mobility. The care plan was revised on 11/15/2024 and documented to provide Resident #1 with preventive skin care, complete a skin risk assessment, assess for skin changes, keep skin clean and dry, and provide incontinent care every two hours.The Physician Order dated 11/06/2025 documented Resident #1 was ordered collagen powder and calcium alginate to treat their stage three sacral and left buttock ulcers. On 12/03/2025, a wound care consult was ordered to evaluate Resident #1's right buttock redness.Wound Care Nurse #2 documented in a Nursing Note dated 12/04/2025 Resident #1's right buttock redness became a stage two pressure ulcer measuring 8cm by 6cm by .1cm with moderate serous drainage.The Wound Note by Wound Physician Assistant #3 dated 12/04/2025 documented Resident #1 had stagnant unhealing stage three sacral and left buttock ulcers. A stage two pressure ulcer with light serous drainage measuring 8cm by 6cm by 1cm located on Resident #1's right buttock and was ordered Silvadene treatment daily.The Physician Orders dated 12/04/2025 documented Silvadene cream was ordered to treat Resident #1's stage two right buttock ulcer.The Nurse Practitioner #1 Note dated 12/09/2025 documented Resident #1 had an infected right buttock ulcer, and the wound care team would follow up.The Wound Note by Wound Physician Assistant #3 dated 12/11/2025 documented Resident #1's wounds remained stagnant, and the left buttock and sacral ulcers were noted with moderate serosanguinous drainage. Santyl ointment was ordered to treat Resident #1's left buttock and sacral ulcers. Silvadene was ordered to treat the right buttock ulcer. The Wound Note by Wound Physician Assistant #3 dated 12/18/2025 documented Resident #1's wounds continued to be stagnant and drained moderate serosanguinous fluid. No changes in measurements, characteristics or treatment orders for Resident #1's sacral, left buttock, and right buttock ulcers.The Wound Note by Wound Physician Assistant #3 dated 12/24/2025 documented Resident #1's wounds continued to be stagnant and drained moderate serosanguinous fluid. There were no changes in measurements, characteristics, or treatment orders for Resident #1's sacral, right buttock, and left buttock ulcers.There was no documented evidence Wound Physician Assistant #3 addressed Resident #1's infected right buttock ulcer or reviewed Resident #1's treatment care plan to address nonhealing pressure ulcers. The Nursing Note dated 12/25/2025 documented Resident #1 was transferred to the hospital for transfusion due to low hemoglobin values.The Certified Nurse Aide Accountability Record for 12/2025 documented Resident #1 laid in the same position in bed for six or more hours 15 days out of the 25 days the resident was in the facility.The Hospital Discharge summary dated [DATE] documented Resident #1 presented in the emergency room for evaluation of severe anemia on 12/25/2025 and their large sacral ulcer was observed to be infected with purulent drainage upon their arrival. A wound culture from 12/25/2025 reported Resident #1 had klebsiella pneumoniae, proteus mirabilis, Acinetobacter, yeast, and staphylococcus organisms present in their wounds. Resident #1 was ordered and began receiving a treatment course of intravenous antibiotics. The sanguinous discharge from Resident #1's sacral ulcer was highly suspicious as the source of Resident #1's infection and anemia.On 04/03/2026 at 12:09 PM, Wound Care Nurse #2 was interviewed and stated they performed treatments daily for all ventilator-dependent residents with pressure ulcers. Wound Care Nurse #2 stated they also made rounds with the wound care specialists every Friday. Wound Care Nurse #2 stated they transcribed the wound care specialist orders by taking exactly what was written in the wound consults under Wound Orders and inputting it into the facility's Physician Orders for the medical doctor to sign off. Wound Care Nurse #2 stated they just provided the ordered treatments to residents on the ventilator unit and any issues related to Resident #1 in December 2025 would have to be deferred to the Nursing Supervisor, Registered Nurse #4. Wound Care Nurse #2 stated they signed the Treatment Administration Reford when providing wound care but do not document any assessment or description of residents' wounds until the wound care specialist has assessed.On 04/03/2026 at 1:15 PM, the Director of Nursing was interviewed and stated they did not recall any concerns with Resident #1's hospitalization in 12/2025 and did not receive any reports from the admitting nursing staff that the hospital paperwork documented any concerns such as infected purulent wounds or a moldy feeding tube. The nursing staff were responsible for documenting the characteristics of a resident's wound daily during treatment administration. Any changes in the wound should be referred to the medical doctor.2) Resident #3 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with vent dependence and cerebral vascular accident.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #3 was severely cognitively impaired, was totally dependent on staff to perform activities of daily living, was at risk for developing pressure ulcer injuries and had one unstageable pressure injury upon admission to the facility. Treatments included a pressure-reducing device for the bed, dressing and ointment application, and turning and repositioning.The Patient Review Instrument dated 07/15/2024 documented Resident #3 had a stage two coccyx pressure ulcer and should be placed on skin and decubitus precautions.The Nursing admission assessment dated [DATE] documented Resident #3 was at high risk for developing pressure ulcers.The Physician admission assessment dated [DATE] documented Resident #3 had an unstageable sacral wound and their treatment plan included assistance with incontinent brief change.Physician Orders dated 07/18/2024 documented orders for Medi-honey daily and as needed and a wound consultation for Resident #3's sacral wound. The Comprehensive Care Plan related to skin breakdown created 07/20/2024 documented interventions to prevent Resident #3 from having skin breakdown included completing a skin risk assessment, providing protective and preventive skin care, monitoring skin during daily care, assessing for changes in skin condition each shift, keeping skin clean and dry, providing incontinent care every two hours, turning and positioning every two hours, elevating legs as needed, and providing appropriate pressure relieving devices as per physical and occupational therapy recommendations.The Physical Therapy Evaluation dated 07/19/2024 documented Resident #3 was awake, able to mouth their name, and able to follow one step commands. Resident #3 had a sacral ulcer and was on fall and safety precautions.There was no documented evidence Resident #3 was evaluated for offloading devices to prevent further skin breakdown.The Wound Note by Wound Physician Assistant #3 dated 7/19/2024 documented Resident #3 had an unstageable sacral ulcer measuring 9cm by 7cm with no depth. Medi-honey treatment was ordered daily and as needed. Physician Assistant #3 documented Resident #3 would have a follow-up wound consultation in one week.Nurse Practitioner #1's Note dated 07/30/2024 documented Resident #3 was evaluated for low blood pressure. Resident #3's skin was dry, bilateral feet had dark skin discoloration, and right lateral skin abrasion was noted. Nurse Practitioner #1 documented fall precautions and intravenous fluid hydration to address Resident #3's condition.The Nursing Note dated 07/31/2024 at 6:01 AM documented Registered Nurse #7 received Resident #3 fully awake and responsive to tactile stimuli during perineal care and wound dressing.The Nursing Note dated 07/31/2024 at 10:11 AM documented Registered Nurse #9 was informed that Resident #3 had an abrasion to their left hip with an opening measuring 4cm by 4cm. Resident #3 was also noted with deep tissue injuries to their right and left heel, right and left ankle, and right hip. Staff were using a draw sheet with Resident #3 to reduce friction and shear.Physician Orders dated 07/31/2024 documented Resident #3 was ordered a wound consult for deep tissue injuries observed to their right and left medial heel, right and left ankle, and right hip. Bilateral heel boots were issued to increase comfort, maintain skin integrity, and limit skin breakdown. Skin prep treatment was ordered twice daily to Resident #3's left and right heel, right hip, and right ankle. Zinc oxide treatment was ordered daily for Resident #3's left hip abrasion.The Certified Nurse Aide Accountability Record for 07/2024 was reviewed and there was no documented evidence turning and positioning assistance were provided to Resident #3 in accordance with the resident's plan of care.The Certified Nurse Aide Accountability Record for 08/2024 was reviewed and documented turning and positioning assistance for Resident #3 every two hours starting 08/08/2024.There was no documented evidence Resident #3 was seen by the wound care specialist within a week of their first assessment on 07/19/2024.On 04/09/2026 at 12:49 PM, the Director of Nursing was interviewed and stated they did not recall Resident #3's stay at the facility. If the resident developed pressure ulcers in the facility, a pressure ulcer investigation would be conducted to determine how the pressure ulcers occurred and what further intervention needed to prevent further skin breakdown. The Director of Nursing stated they would not necessarily do an investigation into an abrasion, which is caused by force and not related to pressure ulcers.On 04/13/2026 at 12:00 PM, Certified Nurse Aide #8 was interviewed via telephone and stated they were assigned to the ventilator unit and actively looked at their assigned resident's skin every time they changed a resident's brief. Turning and repositioning assistance was provided to those residents who triggered for it on their accountability records. Not all residents required assistance with turning and repositioning. Certified Nurse Aide #8 stated they signed the Accountability Record every time they assisted with a task. They informed the licensed nurses if they observe any change sin condition with their assigned residents. Certified Nurse Aide #8 stated they did not have anywhere to document when they observed changes and were dependent on whether the licensed nurses appropriately pursued their reported concerns. The physical and occupational therapists were responsible for bringing offloading and other cushioning devices to the units and in servicing the direct care staff on how to use them with the residents.On 04/13/2026 at 3:12 PM, Registered Nurse #7 was interviewed via telephone and stated they did not recall Resident #3 specifically, Registered Nurse #7 stated they performed skin assessments of all their residents every shift and especially checked their back and bony prominences. Registered Nurse #7 stated they don't know how Resident #3 was able to develop multiple deep tissue injuries on their ankles and heels within a few hours of providing wound care to the resident. Registered Nurse #7 stated they were not aware of any facility investigation conducted to determine how Resident #7 developed these pressure-related injuries and hip abrasion.On 04/13/2026 at 4:06 PM and 04/14/2026 at 10:00 AM, the Assistant Director of Nursing was interviewed via telephone and stated they performed an investigation into Resident #3's facility-acquired deep tissue injuries in 08/2024 and determined that Resident #3's skin issues were unavoidable. The Assistant Director of Nursing stated they were responsible for overseeing the wound care program and could not recall the last time Wound Care Nurse #2 performed a competency related to wound care. The facility did not have an inservice coordinator and Wound Care Nurse #2 received wound care inservice from the facility's wound care specialist vendor.On 04/09/2026 at 11:49 AM, Nurse Practitioner #1 was interviewed and stated they sometimes covered episodic concerns on the ventilator unit. The facility had three nurse practitioners available to address concerns on the ventilator unit and coverage was dependent on who was available. The wound care specialists were responsible for evaluating a resident's wounds, addressing stagnant unhealing wounds, and ordering wound treatments.On 04/10/2026 at 10:23 AM, a telephone interview was conducted with the Pulmonologist who stated they were only responsible for the respiratory care of the ventilator dependent residents. The Pulmonologist stated they were not the primary care physician for any of the residents in the facility and were not responsible for ordering treatments or anything else unrelated to a resident's respiratory condition.10 NYCRR 415.12(c)(2)

Based on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure the physician reviewed the resident's total program of care, including medications and treatments, at each visit for two (Residents #6 and #1) of four ventilator-dependent residents sampled. Specifically, 1) discrepancies in the wound specialist's and the attending physician's ordered treatments were not addressed during physician visits, and 2) there was no evidence the attending physician reviewed labs reporting increasingly abnormal values and wound notes reporting stagnant, unhealing wounds with ongoing drainage.The findings are:1) Resident #6 had diagnoses of chronic respiratory failure with ventilator dependence and cerebral infarction.Resident #6's facesheet documented the Pulmonologist was the resident's Attending Physician.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #6 was severely cognitively impaired and totally dependent on staff to perform activities of daily living. Resident #6 had three unhealed pressure ulcers present on admission to the facility and one unhealed facility-acquired pressure ulcer.The Wound Note dated 03/27/2026 documented treatments be administered daily and as needed to Resident #6's right mid-back, sacral, right medial buttock, right lateral buttock and left lateral leg ulcers.Physician Orders signed by the Pulmonologist dated 03/27/2026 documented treatment orders for Resident #6's mid-back and left lateral leg twice daily and sacral, right medial buttock, and right lateral buttock three times daily. The Treatment Administration Record for 03/2026 documented Resident #6 received treatment to their left lower leg and mid-back twice daily and sacral, right medial buttock, and right lateral buttock three times daily in accordance with Physician Orders on 03/27/2026. There was no documented evidence Resident #1's attending physician, the Pulmonologist, reviewed and addressed treatment orders recommended by the wound care specialist. Subsequent medical notes did not include an evaluation or address recommended treatments from the wound care team. On 03/31/2026 at 11:19 AM and 2:35 PM, Wound Care Nurse #2 was interviewed and stated Resident #6 had wounds to the right inferior mid-back, sacrum, right lateral buttock, middle buttock, and left lateral leg. Resident #6's right buttock wound had purulent discharge and showed signs of infection. Wound Care Nurse #2 stated the wound care specialist verbally recommended treatment orders during weekly wound rounds. Wound Care Nurse #2 stated they transcribed the treatment order recommendations onto the Physica Orders and update the resident's care plan. Resident #6 had wounds with excessive drainage, and their treatment orders were twice daily until last Friday when Wound Care Nurse #2 stated they changed Resident #6's treatment orders to three times daily because they noted the resident still had excessive drainage from their ulcers. Resident #6 has had excessive drainage for at least a week.On 04/03/2026 at 11:34 AM, Wound Physician Assistant #1 was interviewed and stated they did not give recommendations for Resident #6 to receive treatment more than once daily. Resident #6 had pressure ulcers with chronic infections and Wound Physician Assistant #1 stated they would have recommended Resident #6 be hospitalized if they knew the resident required wound care more than once daily for excessive drainage. Wound Physician Assistant #1 stated they assessed Resident #6 today during wound rounds and recommended the resident be hospitalized .2) Resident #1 had diagnoses of chronic respiratory failure with ventilator dependence and hypoxic ischemic encephalopathy.Resident #1's facesheet documented the Pulmonologist was the resident's attending physician.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #1 was severely cognitively impaired, totally dependent on staff to perform activities of daily living and had unhealed facility-acquired stage two and three pressure ulcers.The Physician Order prescribed by the Pulmonologist dated 11/06/2025 documented Resident #1 was ordered collagen powder and calcium alginate to treat their stage three sacral and left buttock ulcers. On 12/03/2025, a wound care consult was ordered to evaluate Resident #1's right buttock redness.The Wound Note dated 12/04/2025 documented Resident #1 had stagnant unhealing stage three sacral and left buttock ulcers. Resident #1 was ordered to continue their current wound treatments. Lab Results dated 12/05/2025 documented Resident #1 had an elevated white blood cell count at 12.79 cubic microliters with a normal reference range of 3.98 to 10.04 cubic microliters. The hemoglobin was low at 7.1g/dL with a reference range of 11.2 to 15-7. The hematocrit was low at 24.4% with a reference range of 34.1 to 44-9%.Lab Results dated 12/08/2025 documented Resident #1's white blood cell count increased to 16.13 cubic microliters. The hemoglobin was 7.0g/dL and hematocrit was 24.2%.Nurse Practitioner #1's Note dated 12/09/2025 documented Resident #1 had an elevated white blood cell count and infected right buttock ulcer. The note documented Resident #1 would be ordered Zosyn, an intravenous antibiotic, and the wound care team would follow up.The Physician Order signed by Nurse Practitioner #3 dated 12/09/2025 documented Resident #1 was ordered a urinalysis, urine culture, and intravenous Zosyn every eight hours for seven days.The Wound Note dated 12/11/2025 documented Resident #1's wounds remained stagnant, and the left buttock and sacral ulcers were noted with moderate serosanguinous drainage. Santyl ointment was ordered to treat Resident #1's left buttock and sacral ulcers. Silvadene was ordered to treat the right buttock ulcer. Nurse Practitioner #3's Note dated 12/13/2025 documented Resident #1 did not have a urinary tract infection according to their urinalysis results from 12/10/2025 and Zosyn was discontinued on day four of seven before being completed. There was no documented evidence Resident #1's attending physician, the Pulmonologist, reviewed and addressed the resident's increasingly abnormal lab values for hemoglobin, hematocrit, and white blood cell counts.The Wound Note dated 12/18/2025 documented Resident #1's wounds continued to be stagnant and drained moderate serosanguinous fluid. There were no changes in measurements, characteristics or treatment orders for Resident #1's sacral, left buttock, and right buttock ulcers.The Monthly Progress Note by the Pulmonologist dated 12/19/2025 documented Resident #1 had pressure ulcers and did not document reference to their unhealing status or recent lab results.The Wound Note dated 12/24/2025 documented Resident #1's wounds continued to be stagnant and drained moderate serosanguinous fluid. There were no changes in measurements, characteristics, or treatment orders for Resident #1's sacral, right buttock, and left buttock ulcers.Lab Results dated 12/24/2025 documented Resident #1's white blood cell count increased to 20.63 cubic microliters.The Nursing Note dated 12/25/2025 documented Resident #1 required a blood transfusion due to low hemoglobin values and was transferred to the hospital.There was no documented evidence the Pulmonologist reviewed and addressed ongoing reports of Resident #1's stagnant, draining, and unhealing pressure ulcers.The Patient Review Instrument dated 12/29/2025 documented Resident #1 had a primary diagnosis of infected stage four decubitus ulcer.The Hospital Discharge summary dated [DATE] documented Resident #1 presented in the emergency room for evaluation of severe anemia on 12/25/2025 and their large sacral ulcer was observed to be infected with purulent drainage upon their arrival. Labs drawn at the hospital on [DATE] documented Resident #1's white blood cell count had increased to over 23.00 cubic microliters. The hospital attempted and were unsuccessful in obtaining more information from the facility nursing staff related to Resident #1's change in condition prior to hospitalization.On 04/03/2026 at 1:15 PM, the Director of Nursing was interviewed and stated they did not recall any concerns with Resident #1's hospitalization in 12/2025 and did not receive any reports from the admitting nursing staff that the hospital paperwork documented any concerns such as infected purulent wounds or a moldy feeding tube. The nursing staff were responsible for documenting the characteristics of a resident's wound daily during treatment administration. Any changes in the wound should be referred to the medical doctor.On 04/09/2026 at 11:49 AM, Nurse Practitioner #1 was interviewed and stated they sometimes covered episodic concerns on the ventilator unit. The facility had three nurse practitioners available to address concerns on the ventilator unit and coverage was dependent on who was available. The wound care specialists were responsible for evaluating a resident's wounds, addressing stagnant unhealing wounds, and ordering wound treatemnts.On 04/09/2026 at 3:54 PM, the Medical Director was interviewed via telephone and stated the Pulmonologist was assigned as attending physician for the ventilator dependent residents in the facility. The Medical Director stated they were assigned as primary care physician to other residents in the facility and assisted with coverage of the ventilator unit when the Pulmonologist was not available. Questions related to the care of residents on the ventilator unit should be directed to the Pulmonologist. The Medical Director stated the facility's clinicians, including the Medical Director and the Pulmonologist, were responsible for ensuring the wound care specialists were addressing the resident's care plan that orders were carried out. On 04/10/2026 at 10:23 AM, a telephone interview was conducted with the Pulmonologist who stated they were only responsible for the respiratory care of the ventilator dependent residents. The Pulmonologist stated they were not the attending physician for any of the residents in the facility and were not responsible for ordering treatments or anything else unrelated to a resident's respiratory condition.On 04/14/2026 at 11:09 AM, the Administrator was interviewed and stated the Pulmonologist was not the attending physician for the facility's ventilator dependent residents and they did not know anything about the Pulmonologist's designation on Resident #1's and Resident #6's facesheets as their attending physician. The Administrator stated the Medical Director, and the nurse practitioners were responsible for working together to cover the ventilator unit and address resident clinical needs.10 NYCRR 415.15(b)(2)(iii)

Based on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure services provided by the facility met professional standards of quality for two (Residents #1 and #6) of five residents sampled for pressure ulcer review. Specifically, 1) Wound Care Nurse #2 transcribed treatment orders received from the Wound care Physician for Resident #6 to occur more frequently than recommended 2) Wound Care Nurse #2 made changes to treatment orders for Resident #1 that were not recommended by the wound care specialist.The findings are:1) Resident #6 had diagnoses of chronic respiratory failure with ventilator dependence and cerebral infarction.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #6 was severely cognitively impaired and totally dependent on staff to perform activities of daily living. Resident #6 had three unhealed pressure ulcers present on admission to the facility and one unhealed facility-acquired pressure ulcer.The Nursing Note dated 03/23/2026 documented Resident #6 was readmitted from the hospital after receiving a blood transfusion for anemia and had sacral, right mid-back, right buttock, and left lateral leg pressure ulcers.The Physician Orders transcribed by Registered Nurse #7 dated 03/23/2026 documented Resident #6 was ordered treatment to their right mid-back and right lateral buttock daily and as needed. Resident #6's right medial buttock, sacral, and left lower leg ulcers were ordered treatment twice daily and as needed.The Wound Note dated 03/27/2026 documented Wound Physician Assistant #1 ordered treatments to be administered daily and as needed to Resident #6's right mid-back, sacral, right medial buttock, right lateral buttock and left lateral leg ulcers.Physician Orders transcribed by Wound Nurse #2 dated 03/27/2026 documented treatment orders for Resident #6's mid-back and left lateral leg twice daily and sacral, right medial buttock, and right lateral buttock three times daily. The Treatment Administration Record for 03/2026 documented Resident #6 received treatment to their left lower leg and mid-back twice daily and sacral, right medial buttock, and right lateral buttock three times daily in accordance with Physician Orders from 03/27/2026 until the resident's hospitalization on 04/03/2026. On 03/31/2026 at 11:19 AM and 2:35 PM, Wound Care Nurse #2 was interviewed and stated Resident #6 had wounds to the right inferior mid-back, sacrum, right lateral buttock, middle buttock, and left lateral leg. Resident #6's right buttock wound had purulent discharge and showed signs of infection. Wound Care Nurse #2 stated the wound care specialist verbally recommended treatment orders during weekly wound rounds. Wound Care Nurse #2 stated they transcribed the treatment order recommendations onto the Physician's Orders and updated the resident's care plan. Resident #6 had wounds with excessive drainage, and their treatment orders were twice daily until 03/27/2026 when Wound Care Nurse #2 stated they changed Resident #6's treatment orders to three times daily because they noted the resident still had excessive drainage from their ulcers. Resident #6 has had excessive drainage for at least a week.On 04/03/2026 at 11:34 AM, Wound Physician Assistant #1 was interviewed and stated they did not give recommendations for Resident #6 to receive treatment more than once daily. Resident #6 had pressure ulcers with chronic infections and Wound Physician Assistant #1 stated they would have recommended Resident #6 be hospitalized if they knew the resident required wound care more than once daily for excessive drainage. Wound Physician Assistant #1 stated they assessed Resident #6 today during wound rounds and recommended the resident be hospitalized .2) Resident #1 had diagnoses of chronic respiratory failure with ventilator dependence and hypoxic ischemic encephalopathy.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #1 was severely cognitively impaired, totally dependent on staff to perform activities of daily living and had unhealed facility-acquired stage two and three pressure ulcers.The Wound Note by Wound Physician Assistant #3 dated 12/24/2025 documented a wound order for Silvadene to Resident #1's right buttock ulcer. The Nursing Note written by Wound Nurse #2 dated 12/24/2025 documented Wound Physician Assistant #3 evaluated Resident #1 and changed the right buttock treatment to Santyl ointment.The Physician Order transcribed by Wound Nurse #2 dated 12/24/2025 documented Resident #1's right buttock treatment was changed to Santyl ointment. On 04/13/2026 at 4:06 PM and 04/14/2026 at 10:00 AM, the Assistant Director of Nursing was interviewed and stated they were responsible for overseeing the wound care program and could not recall the last time Wound Care Nurse #2 performed a competency related to wound care. The facility did not have an inservice coordinator and Wound Care Nurse #2 received wound care inservice from the facility's wound care specialist vendor. The Assistant Director of Nursing stated the nurses on the ventilator unit reported that all residents with pressure ulcers required a dressing change more than once daily because every time they soiled their incontinence brief, the resident's dressings became soiled. The Assistant Director of Nursing stated residents should be ordered treatments according to the wound care specialist recommendations and should be provided more than once daily only as needed.10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews, and record review conducted during an abbreviated survey, the facility did not ensure infection prevention and control standards were maintained during wound care to prevent the spread of infection to other wounds for 1 (Resident #6) of 2 residents observed for wound care. Specifically, Resident #6's uncovered back and buttock wounds were observed having direct contact with a towel soaked with purulent drainage from soiled dressings removed from the resident's infected right buttock ulcer. The findings are:Resident #6 had diagnoses of chronic respiratory failure with ventilator dependence and cerebral infarction.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #6 was severely cognitively impaired and totally dependent on staff to perform activities of daily living. Resident #6 had three unhealed pressure ulcers present on admission to the facility and one unhealed facility-acquired pressure ulcer.Physician Orders transcribed dated 03/23/2026 documented Resident #6 was on contact precautions for an infection in their right buttock wound. Physician Orders dated 03/27/2026 documented treatment orders for Resident #6 to receive mupirocin 2% topical ointment and calcium alginate packing to their right and medial buttock, Thera-honey gel to the sacrum and right mid-back, and Medi-honey with hydrogel to their left lateral leg. On 03/31/2026 at 11:19 AM and 2:35 PM, Wound Care Nurse #2 was interviewed and stated Resident #6's right buttock wound had purulent discharge and showed signs of infection. Infection control was important to prevent the resident's other wounds from becoming infected.On 03/31/2026 at 11:43 AM, during wound care observation of Resident #6, Resident #6 was observed positioned onto their left side and off their back with Certified Nurse Aide #3 holding onto the resident's right side, while Wound Care Nurse #2 removed three dressings from the resident's right lateral and medial buttock, mid-back and sacrum. Wound Care Nurse #2 did not place a barrier between the resident and the towel soiled from the old dressing. Wound Care Nurse #2 stepped away from Resident #6 to change their gloves and obtain more treatment supplies, Certified Nurse Aide #3 dropped Resident #6 slightly onto their back, allowing the resident's sacral and buttock wounds to touch the towel soaked in multiple spots with dark red drainage. There was no barrier placed between Resident #6's wounds and the towel.On 03/31/2026 at 2:35 PM, Wound Care Nurse #2 was interviewed and stated Resident #6's bed should have had a drop cloth barrier in between the resident and the sheets they were laying on to prevent infection and/or cross-contamination from other infected wounds to wounds without infection. Wound Care Nurse #2 stated they forgot to place a drop cloth on the bed under Resident #6 before the dressing change.On 04/14/2026 at 10:00 AM, the Assistant Director of Nursing was interviewed via telephone and stated besides Wound care Nurse #2, they were also in charge of infection control but have not observed Wound Care Nurse #2's treatment practices. Residents should always be provided with drop cloth barriers to prevent their open wounds from coming into contact with potentially soiled objects. 10 NYCRR 415.19 (b)(4)

Based on record review and interview conducted during the abbreviated survey (2581942), the facility failed to ensure all residents were free of accident hazards and that each resident received assistance to prevent falls for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, Resident #1 sustained a head injury after a fall from their bed on 08/05/2025. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.Findings include: The policy titled 'Fall Prevention Program' issued 03/28/2021 and reviewed 05/30/2025 documented all residents, by virtue of age, illness/injury and placement, are considered to be at risk for falls. A falls risk assessment will be completed on admission and quarterly to identify specific risk and develop an individualized care plan. The policy titled 'Turn and Positioning in Bed: Proper Technique' effective 01/28/2020 and reviewed 05/29/2025 documented the procedure of turning a resident to side lying position. The procedure included gently roll him towards you. (NEVER AWAY). The policy further documented Turning A Resident in Bed, Important points to remember included stand and face the direction of the move to be made, stand close to the object or resident to be moved; keep the load as close to you as possible. Resident #1 was admitted on [DATE] with diagnoses including, but not limited to, cerebrovascular disease (condition that affects blood flow to your brain), chronic respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide), and anemia (low levels of healthy red blood cells). The 11/27/2023 admission Fall Risk Assessment documented Resident #1 was a low risk. The 11/28/2023 Activities of Daily Living care plan documented Resident #1 was dependent for toileting hygiene, dependent for personal hygiene, dependent to roll left and right. The 11/30/2023 Fall/Injury care plan documented Resident #1 had cardiovascular disease, cerebrovascular accident (stroke), and incontinence. Interventions included to anticipate the needs of resident with regards to activities of daily living, rehabilitation referral for evaluation secondary to fall, evaluate the pattern of falls if resident fell more than once and investigate cause of the fall immediately. The 05/04/2024 Certified Nurse Aide Instruction documented one (1) person physical assist for bed mobility. The 06/23/2025 Quarterly Minimum Data Set assessment documented Resident #1 had severe cognitive impairment, required partial/moderate assistance roll left to right, and had no history of falls. The 08/05/2025 Fall Incident Report completed by Nursing Supervisor #1, documented the resident rolled over from the bed and fell to the floor when Certified Nurse Aide #1 turned them to the right side. Resident was found lying on their back with laceration/hematoma (a tear or cut in the skin/bruise) on left side of forehead, bruising on right hand and abrasion on left knee. No changes in level of consciousness, alert and oriented x3 (alert and oriented to person, place and time), no changes in range of motion. Physician and next of kin were notified. The incident report concluded that no abuse, neglect or mistreatment occurred. The 08/05/2025 7:14 AM progress note written by Nursing Supervisor #1 documented Resident #1 was observed lying on their back on the right side of the bed. On assessment, Resident #1 sustained laceration/hematoma on the left side of their forehead. Bleeding noted on the site. Bruising noted on the right hand and abrasion on the left knee. Resident #1 complained of pain on their left forehead. Wheezing noted on auscultation. Blood pressure 162/78, pulse rate 121, respiration rate 20, temperature 97.7, and oxygen saturation 97% at room air. The 08/05/2025 Summary of Investigation completed by Assistant Director of Nursing documented resident was dependent on bed mobility required assist of one (1) when rolling from left to right when in bed. Had a fall, sustained hematoma on left side of forehead and was transferred to the hospital. The investigation documented that as per Certified Nurse Aide #1, they positioned the Resident #1 on the side, rolled the dirty linen underneath the resident and was reaching for clean linen and chux (absorbent pad). While providing the care, the resident rolled unexpectedly, and Resident #1 started to slide off the bed. Certified Nurse Aide #1 tried to grab the resident but could not break the fall. Nursing Supervisor reported resident had laceration/hematoma on the left side of forehead, bleeding noted. Resident was transferred to the hospital. The finding of computed tomography (CT) scan of the head done at the hospital showed diffuse subarachnoid hemorrhage (bleeding into the space between the brain and the membranes that cover it) in the frontal lobe, right parietal lobe and right temporal lobe. Left sided subdural hematoma (a collection of blood between the brain and the dura mater, the tough outer layer of the brains protective covering). The Medical Director reviewed the result of the hospital computed tomography scan, determined that the subarachnoid hemorrhage occurred before the fall and not as a result of the fall. During an interview on 10/10/2025 at 10:59 AM, Medical Director stated that they remembered the resident had a fall and was transferred to the hospital. They reviewed the computed tomography scan that was done at the hospital and stated that the subarachnoid hemorrhage could have happened before or after the fall. Resident had multiple comorbidities that could cause subarachnoid hemorrhage. During a phone interview on 10/10/2025 at 12:22 PM, Certified Nurse Aide #1 stated that they remembered Resident #1 had a fall. Resident #1 was able to turn in bed with assistance of one (1) person and there was no side rail or grab bar on their bed. They stated that they gave care and changed the resident's diaper and chux in bed. They stated that they turned the resident away from them towards the wall and rolled the diaper and chux under the resident. They then reached for the clean chux which they placed at the foot of the bed. Certified Nurse Aide #1 stated the resident lifted their hip and fell off the bed to the left side on the floor. They stated they called out for a nurse, and the supervisor came to the room. They stated Resident #1 said, I fell out of bed. Certified Nurse Aide #1 stated they stayed with the resident and explained to Nursing Supervisor #1 that they turned the resident to the opposite side and resident fell. During an interview on 10/10/2025 at 12:39 AM, Nursing Supervisor #1stated they were called to the unit. They stated that Resident #1 was seen on the floor, face down, with a bump on the forehead with bleeding. Nursing Supervisor #1 stated they assessed the resident's range of motion and Resident #1 had no complaint, no change in level of consciousness. Certified Nurse Aide #1 demonstrated to them that they turned Resident #1 on the opposite side away from them. Resident #1 was turned to the right side and Certified Nurse Aide #1 was on the left facing the door. Nursing Supervisor #1 stated they told Certified Nurse Aide #1 they must be on the side where they turn the resident. They further stated that they told Certified Nurse Aide #1 to call for help if they turn the resident away from them. Nursing Supervisor #1 stated that Certified Nurse Aide #1 did not say they called for help. Nursing Supervisor #1 stated Resident #1 was alert. Nursing Supervisor #1stated they told resident they were bleeding and had to go to the hospital. During a subsequent phone interview on 10/14/2025 at 2:51 PM, the Medical Director stated the information was communicated to them that a resident had a fall from bed when Certified Nurse Aide #1 was changing the resident. The Medial Director stated the decision was made to send the resident to the hospital because there was a hematoma on the resident's head. During an interview on 10/14/2025 at 4:03 PM, the Director of Nursing stated they remembered the resident's fall. The Director of Nursing stated because of the fall, the resident sustained a hematoma and laceration on left side of their forehead. The physician was notified, and the resident was transferred to the hospital. 10NYCR 415.12(h)(2)

Based on interview, observation and record review during a Recertification Survey conducted from 8/26/2024 through 8/30/2024, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and to prevent the development of pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. This was evident for 1 of 4 residents reviewed for pressure ulcers (Resident #24). Specifically, Resident #24 was assessed as high risk for pressure ulcers and was identified to have left heel redness on 08/24/2024. The resident's care plan and interventions were not promptly updated and implemented to prevent further deterioration of the left heel skin integrity. Subsequently, on 8/29/2024, the resident's left heel was observed and assessed by the facility nurse practitioner and diagnosed to be an unstageable decubitus (damage to a person's skin caused by constant pressure on an area for a long-time) ulcer. This resulted in actual harm to Resident #24 that is not Immediate Jeopardy. The findings are: The facility's policy titled Pressure Ulcers: Prevention and Care of (dated 5/2001, revised 6/2012) documented it is the policy of the facility to maintain the skin integrity of residents with intact skin and to restore the skin integrity of those residents with pressure ulcers. Actions include: may refer to the Pressure Ulcer Protocol, initiate the resident's care plan with nursing interventions for treatment and prevention of the pressure ulcer, review and update care plan accordingly, may convene a care planning team meeting including the dietician, rehabilitation therapist, physician or nurse/wound care team to develop the interdisciplinary steps required for healing the ulcer, update the interdisciplinary team to reflect the physicians orders and any other interventions decided upon. Supervise care rendered by Certified Nursing Assistant (CNA) to assure optimal positioning (including use of devices) and incontinence care. The undated facility policy for Turning and Positioning a Resident documented turning and positioning of resident in bed is performed as specified in the resident plan of care. The following residents are to be considered for a specified turning and positioning schedule: residents identified as high risk for pressure ulcer development, residents with actual skin ulcer, and residents with limited bed mobility. The Facility Pressure Ulcer Protocol for Care for Stage 1 pressure ulcer guidelines identifies a Stage 1 ulcer definition as intact skin with redness (in darker skin may appear as red/blue or purple hues) of a localized area which is usually over a bony prominence). Please note not all reddened areas are stage 1 pressure ulcers. Some reddened areas are due to moisture associated with skin damage. Guidelines for Interventions include: complete full body assessment on admission, hospital return, during bed bath, shower, incontinent care or anytime when red area is noted, skin assessment to be completed by registered nurse on admission, quarterly and for significant change. May update plan of care with turn and repositioning task. Turn and position for relief of pressure, if applicable. Reduce shear and friction, lubricate skin, inform physician and dietician, provide resident/family/staff education and document on the resident/family care plan, documentation in medical record on staging, location, and treatment, update comprehensive care plan/minimum data set as necessary. Resident #24 had diagnoses including type 2 diabetes, Alzheimer's disease, and a history of pressure injuries. The Quarterly Minimum Data Set (an assessment tool) dated 7/15/2024 documented Resident # 24 had severe cognitive impairment, was dependent on staff for chair/bed-to-chair transfers and required substantial to maximal assistance for bed mobility and sitting on the side of the bed. Resident #24 was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, had no pressure ulcers/other skin problems (ulcers, wounds), had a pressure reducing device for chair/bed, was on a turning/repositioning program, received nutrition or hydration intervention to manage skin problems, and received ointments/medications other than to feet. The 8/19/2024 Skin Integrity Care Plan documented Resident #24 was at risk for skin breakdown or pressure ulcer injury. The goal was to have no skin breakdown for 90 days. Interventions included turn and position every 2 hours / as needed, monitor skin during daily care, assess for changes in skin condition each shift, and provide incontinent care every 2 hours and as needed. On 8/26/2024 a wound consult secondary to redness of left heel was added to the care plan. The 8/24/2024 Braden Scale (an assessment used to predict a resident's risk of developing pressure sores/ulcers) documented a score of 11 which indicated that resident was at high risk. The risk factors documented sensory perception: very limited. Moisture: very moist. Activity: chairfast. Mobility: very limited. Nutrition: probably inadequate. Friction and shear: problem. There was no documented evidence Resident #24's care plans were updated to include interventions for the left heel redness and to prevent the further deterioration of left heel skin integrity. The 8/24/2024 Care Plan Activity Report for care area: pressure ulcer/injury/skin integrity potential for skin breakdown note documented: It was reported to the writer that the resident had left heel redness, seen, and examined by nurse practitioner, order zinc ointment to be applied to affected area after cleansing with normal saline then cover with foam dressing every shift and as needed. Wife made aware personally. All needs being attended and anticipated. Morning care done, assisted from bed to geriatric chair (large padded reclining chair with wheeled base for people with limited mobility). Kept clean and dry. Continue plan of care. Currently monitored. The Certified Nursing Assistant Documentation History Detail report documented skin checks were performed each shift (3 times a day) by staff from 8/24/2024 through 8/28/2024. The 8/24/2024 at 3:18 PM Nurse Practitioner note documented left heel skin changes. Came to resident secondary to family informing the left heel had skin changes. Skin on left heel had redness with some bleeding. Changes in left heel skin integrity, wound consultation. Start zinc oxide. The 8/24/2024 at 3:50 PM Nursing Progress note documented resident in bed, awake, calm not in any distress. Noted with redness on their left heel, seen by Nurse Practitioner with treatment advised, cleansed with normal saline, applied zinc oxide and covered with foam dressing as ordered. Out of bed at lunch time. Plan of care to continue. There was no documented evidence of further interventions, or progress notes until 8/29/2024. The August Treatment Administration Record documented Resident #24 received treatment each shift (7 AM- 3 PM, 3 PM-11 PM, 11 PM-7 AM) of topical zinc oxide 20%, apply by topical route every shift to left heel after cleansing with normal saline, then cover with foam dressing from 8/24/2024 through 8/28/2024. The Certified Nurse Aide Documentation Record dated August 2024 documented the resident was turned and positioned every 2 hours from 8:00 PM to 8:00 AM. There was no documented evidence the resident was turned and positioned between 8:00 AM and 8:00 PM. The 8/26/2024 at 3:06 PM Interim Physician Order signed by the Medical Director on 8/27/2024 at 9:54 AM documented wound consult for left heel redness. During observation on 08/27/2024 at 9:34 AM Resident #24 was sleeping on their back in a geriatric chair with their heels resting directly on the geriatric chair footrest. The heels were not off-loaded or elevated. During observation on 08/27/2024 at 11:42 AM Resident #24 was resting on their back in a geriatric chair with their ankles crossed and their heels resting directly on the geriatric chair footrest. Heels were not off-loaded and Resident #24 had socks and slippers on. During a continuous observation on 08/28/2024 from 8:50 AM to 11:41 AM Resident #24 was resting on their back with their ankles crossed and heels resting on the footrest. Resident #24 had socks and slippers on and was not turned/repositioned during this time. During an interview on 08/28/2024 at 1:20 PM Resident #24's family member stated they noticed left heel redness during a visit last week and requested staff to look at the heel. The family member was not aware of any interventions put in place except a request for wound consult to take place Friday, August 30, 2024. During observation on 08/29/2024 at 8:35 AM Resident #24 was resting in bed on their back and their heels were not off-loaded. During observation and interview with Registered Nurse #26 on 08/29/2024 at 9:55 AM, Resident # 24's heels were resting on an air mattress and not off-loaded. The left heel was observed with a soiled, white gauze dressing which was removed by Registered Nurse #26. During an immediate interview, Registered Nurse #26 stated it was an unstageable wound and they were not aware why the wound was dressed in white gauze, not in foam dressing as ordered or why heels were not off-loaded. Registered Nurse #26 did not have an explanation when asked what interventions were implemented to prevent further decline of the heel after report of heel redness on 8/24/2024. Further review of the August 2024 Treatment Administration Record revealed Registered Nurse #26 signed for the heel dressing treatment for the 7:00 AM to 3:00 PM shift on 8/25/2024, 8/26/2024, 8/27/2024, and 8/28/2024. On 08/29/2024 at 10:00 AM, Registered Nurse Supervisor #1 was asked to observe the left heel wound with Registered Nurse #26. During an immediate interview Registered Nurse Supervisor #1 stated, the wound was not stageable and there were areas of necrosis (dead tissue) present. Registered Nurse Supervisor #1 stated they did not know why Resident #24's heels were not off-loaded and was unaware of interventions put in place when redness of the left heel was identified on 8/24/2024. They did not know why the wound was covered with gauze and did not have a foam dressing present as ordered. During observation and interview on 08/29/2024 at 11:59 AM Nurse Practitioner #27 stated the left heel wound was unstageable and had progressed from heel redness which was reported 8/24/2024. Nurse Practitioner #27 stated nurse judgement should have been applied and heel off-loading, turning and repositioning and heel boots should have been added to the care plan immediately upon report of heel redness. During an interview on 08/29/2024 at 1:21 PM, Certified Nursing Assistant #28 stated they report all changes in resident status to the floor registered nurse or Unit Supervisor. Certified Nursing Assistant #28 stated they had not noticed any changes in Resident #24's skin during care since Sunday, August 25, 2024, and Resident #24 was not discussed during reports over the last week. Certified Nursing Assistant #28 stated the resident's family member asked them to check resident's left heel about 4-5 days ago and they informed family member they would provide information to floor registered nurse to assess. Certified Nursing Assistant #28 stated they informed the floor registered nurse of the family member request to assess the left heel. Certified Nursing Assistant #28 stated they were not aware of any interventions put in place for the residents left heel. During an interview on 08/29/2024 at 1:33 PM Registered Nurse #26, stated skin assessments were only completed if there is a change reported and during wound care. Registered Nurse #26 stated they are familiar with Resident #24 and the resident has a wound on the left heel. Registered Nurse #26 stated offloading and repositioning are techniques used to prevent pressure ulcers and they did not routinely off-load the resident's heels except for once on 8/28/2024 when they returned the resident to bed in the evening. Registered Nurse #26 stated the resident is repositioned at mealtimes when in the day room and was not able to provide an answer why the resident was not repositioned every two hours while in the day room or why their heels were not off-loaded while the resident was in the geriatric chair. Registered Nurse #26 stated they should have delegated the task. The 8/29/2024 Nursing progress noted documented the resident was seen and examined by the nurse practitioner with the family at the bedside for a left heel diabetic unstageable ulcer. The nurse practitioner ordered to start Santyl 250 topic ointment to the affected area once daily for 30 days to left heel wound after cleansing with normal saline then cover with foam dressing. To off load bilateral heels with pillows every shift while on bed, to continue to reposition every 2 hours and as needed. Also ordered chest and heel x-ray and lab work. Needs attended to and kept monitored. During interview and observation on 08/30/2024 at 9:15 AM Wound Consultant Nurse Practitioner stated the left heel wound was unstageable. They stated pressure ulcer preventative measures could have been put in place when redness was reported on 8/24/2024 including skin prep, heel booties, off-loading, elevating feet, turning and repositioning every two hours. The staff could have taken a picture and sent it to them, and they could have made a referral to physical therapy and occupational therapy to address the resident crossing their legs and for assistive devices. During interview on 8/30/2024 at 12:03 PM the Director of Nursing stated when a change in skin integrity is reported, the resident should be assessed by the unit registered nurse and an assessment requested from the facility nurse practitioner. Once registered nurse assessment is completed, registered nurse should enter care plans, document notes, notify family of changes and plan of care. Director of Nursing stated interventions should be started immediately based on nursing judgement and orders. Interventions include off-loading, turning and repositioning, resident taken out of bed for period of time, personal hygiene, nutrition review for supplements, supportive devices including cushions, heel boots, hand rolls and possibly, x-rays. Labs including albumin should be ordered. Director of Nursing stated residents at risk for pressure ulcers should be assessed for devices such as chair cushions, heel booties and hand rolls. During interview on 08/30/2024 at 1:30 PM the Medical Director stated the expectation for residents who were at risk for pressure ulcers, included off-loading to begin immediately, turning and repositioning every two hours, efforts to minimize skin excoriation by changing residents frequently, booties used if applicable, and skin barrier ointment. 10 NYCRR 415.12(c)(1)

Based on staff interview and review of facility records during the recertification survey from 8/26/24 through 8/30/24, the facility did not ensure Certified Nurse Aides (CNAs) performance reviews were completed at least once every 12 months. Specifically, eight of eight randomly selected certified nurse aides (CNAs) (#3, #6, #14, #16, #17, #18, #19 and #20) did not have a performance review documented at least once every 12 months. Findings include: The Certified Nurse Aides (CNAs) (#3, #6, #14, # 16, #17, #18, #19 and #20) last performance evaluations were not available. Review of Certified Nurse Aides (CNAs) (#3, #6, #14, #16, #17, #18, #19 and #20) hire dates, provided by the facility, revealed all eight of the certified nurse aides had been working at the facility for more than one year, their hire dates ranges from 2002 through 2021. When interviewed on 8/29/24 at 8:49 AM, Certified Nurse Aide (CNA) #3 stated they could not recall when they had a performance evaluation done. When interviewed on 8/29/24 at 8:52 AM, Registered Nurse Unit Supervisor #1 stated they were responsible for Certified Nurse Aide yearly Performance Evaluations on the 3-11 shift, and they could not explain why they were not completed. When interviewed on 8/28/24 at 3:38 PM, Staffing Coordinator #12 stated the Nurse Educator/Supervisor #13 and the Nursing Supervisors were responsible for completing the Certified Nurse Aides' yearly performance evaluations. Staffing Coordinator #12 stated they were responsible for keeping tract of all the yearly performance evaluation when they were due. 10NYCRR 415.26 (c) (2) (iii)

Based on observation, interview and record review conducted during the recertification survey from 8/26/24 through 8/30/24 the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during interviews and the Resident Council Group meeting that the facility was short staffed at times, and this resulted in call bells not being answered timely and residents not getting out of bed; 2) several nursing staff members reported a lack of sufficient staffing; and 3) an analysis of the actual staffing schedule showed that on multiple occasions from 7/25/24 to 8/25/24, the facility was below the minimum levels documented on the Facility Assessment. Findings include: During a Resident Council meeting on 8/27/24, several residents stated that the facility was short staffed at times, especially on various shifts or on weekends. Residents stated that the call lights ring for a while before someone answers them; and some stated they had to stay in bed when they did not want to stay in bed. On 8/26/24 at 12:06 PM, during an interview with Resident #362, they stated when they rang the call bell, they had to wait for 2 hours to be taken to the bathroom and on several occasions the staff did not attend to their bathrooms needs and would only come to assist them when they were doing their cares. Resident #362 stated in the Residents' Council Group meeting on 8/27/24, they were late for their therapy session on two occasions because the staff got them out of bed late. On 8/27/24 at 09:31 AM, Resident #55 stated in the Resident's Council Group meeting the facility was short staffed on the weekends, and they had to stay in bed all day. Resident #55 stated this occurred last Sunday (8/25/24), they were in bed all day and was upset they could not get up. Resident #55 also stated the facility did not have enough staff to care for their needs. Review of the facility staffing sheets from 7/25/24 through 8/25/24, and the Facility Assessment for residents to direct care nursing staff ratios, documented the facility was understaffed 19 days of 31 days covering various shifts as reviewed for direct care nursing staff. In addition, on 8/25/24 the facility was understaffed of direct care nursing staff for 24 hours as reported in the Resident Council Group meeting on 8/27/24 where Resident #55 stayed in bed all day. On 8/28/24 at 11:06 AM, during an interview with Staffing Coordinator #12, they stated the facility utilized 4 staffing agencies to cover the regular staff vacations, medical leave, and resignations. The Staffing Coordinator #12 stated when there was short notice where the regular staff cannot cover their shift, another staff on duty would be asked to work a double shift before using the agency staff, this occurred two times weekly. On 8/29/24 at 8:49 AM, an interview with Certified Nurse Aide #3 stated they did a double shift for the facility at least three times per week. On 8/30/24 at 12:59 PM, an interview with Certified Nurse Aide #14 stated there were times it was impossible to get all the residents out of bed when the facility was short staffed. On 8/30/24 at 1:04 PM, an interview with Certified Nurse Aide #29 stated they prioritized by getting the residents that had therapy out of bed first when they were short staffed. They also stated when the facility was short of direct care workers, they could not get all 40 residents out of bed. They stated they did double shifts for the facility two times per week. On 8/30/24 at 1:14 PM, an interview with Certified Nurse Aide #6 stated they worked double shifts two times per week for the facility. On 8/30/24 at 2:19 PM, an interview with the Direct of Nursing (DON) stated the facility had good staffing of nurses and certified nurse aides. They stated the facility also had 3 helpers that assisted with answering the call bells, picking up the residents' meal trays and taking the residents' out for their appointments, but they did not give direct care to the residents. 10NYCRR 415.13(A)(1) (i-iii)

Based on observation, record review and interviews during the recertification survey from 8/26/2024 to 8/30/2024, the facility did not ensure that each resident received necessary respiratory care including oxygen therapy that was in accordance with professional standards of practice and as ordered by the practitioner for 1 (Resident #308) of 4 residents reviewed for respiratory care. Specifically, for the Resident #308, the facility did not ensure the physician's order for the prescribed oxygen administration was followed. Findings include: Resident #308 had diagnoses including chronic respiratory failure with hypoxia, shortness of breath, and pneumonia. The Admission Minimum Data Set (resident assessment tool) dated 8/26/24 documented, Resident #308 was admitted to the facility on [DATE], had intact cognition, needed maximal assistance with toileting hygiene, shower/bathe self, lower body dressing, sit to lying, chair to bed transfer, and was dependent with toilet transfer. The resident had shortness of breath with exertion, sitting at rest, lying flat. The resident received oxygen therapy. During observations on 08/26/24 at 9:33 AM and 8/27/24 at 9:20 AM, Resident #308 was in their bed, wearing a nasal canula with a tube connected to the oxygen concentrator with 4 and 4.5 liters per minute flow oxygen. The resident stated that they were on the oxygen continuously since they were admitted to the facility. The physician order dated 8/21/24, documented continuous oxygen at 2-3 liters per minute via nasal canula. Review of the Treatment Administration Records dated 8/20/24 to 8/27/24 for 7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM shifts, documented staff initials for oxygen at 2-3 liters per minute via nasal canula every day, every shift. During observation and interview on 08/27/24 at 11:55 AM, Resident #308 was in their room and receiving oxygen via nasal canula. Registered Nurse #21 observed the oxygen concentrator and turned the flow adjustment knob from 4.5 liters to 2 liters. Registered Nurse #21 stated the the order was for 2 liters per minute. Registered Nurse #21 opened their computer and reviewed the order and the August 2024 Treatment Administration Record and stated the order was continuous oxygen at 2-3 liters via nasal canula and did not know why the order was not being followed. 10 NYCRR 415.12(k) (6)

Based on observation, record review and staff interviews during the recertification survey from 8/26/24-8/30/24, the facility did not ensure that needed services, care and equipment were provided to assure that residents with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for 3 of 3 residents (Residents # 24, #54 and #91) reviewed for position and mobility. Specifically, Residents #24, #54, and #91 were care planned for hand rolls and were observed on multiple occasions without their hand rolls. Findings include: The 2/14/22 policy and Procedure Titled Splints and Bracing documented Splinting and Bracing are provided on order by the resident's primary physician or by the facility Medical Director. The purpose was to improve function and help restore or maintain range of motion. 1. Resident #24 was admitted to the facility with diagnoses including diabetes, Alzheimer's disease, and dysphagia (difficulty swallowing). The Quarterly Minimum Data Set (an assessment tool) dated 7/15/24 documented the resident had severe cognitive impairment and was dependent on staff for activities with activities or daily living. A care plan titled Palm guard care plan (Posey Roll) dated 7/25/24 documented interventions included bilateral Posey hand rolls to be worn as tolerated by resident. The hand rolls could be removed for bathing/dressing/range of motion and skin checks by nursing per their protocol. During observations on 08/27/24 at 9:34 AM and 11:42 AM, 08/28/24 from 8:50 AM to 11:41 AM, and 08/29/24 at 8:35 AM, Resident #24 did not have hand rolls in place. During an interview on 08/28/24 at 1:20 PM, a family member stated they were concerned about resident's hands as they have found the resident with their hands clenched and a smell coming from the inside of their hands on numerous occasions. They stated they had never seen the resident with hand rolls in place and had not observed the hand rolls in the resident's room. The family member stated they washed the resident's hands during visits, applied lotions and cut their fingernails as necessary. The family member stated a discussion regarding hand rolls had not taken place and they were not aware devices were available to resident. During an interview on 8/28/24 at 3:22 PM, Certified Nursing Assistant #3 stated they were not aware of resident wearing hand rolls. During an interview on 8/29/24 at 10:47 AM, Unit Supervisor Registered Nurse #1 stated that a care plan was in place for bilateral hand rolls for Resident #24. Registered Nurse #1 was unable to locate an order for bilateral hand rolls in electronic medical record during interview. They stated that communication did not occur between occupational therapy and nursing staff when the care plan was entered, and the order was not placed. They stated that order should have been placed by the occupational therapist when care plan was entered. During an interview on 08/29/24 at 1:21 PM, Certified Nursing Assistant #28 stated they were not aware of the resident wearing bilateral hand rolls. During an interview on 08/29/24 at 2:02 PM, Registered Nurse #26 stated that Resident #24 had not had hand rolls in place since they returned to the unit in early August 2024. Registered Nurse #26 stated they would usually report to physical therapy if a resident had contractures, or they would inform the supervisor. Registered Nurse #26 stated they did not report contractures to the unit supervisor or physical therapy. During an Interview on 08/30/24 at 9:39 AM, Occupational Therapy Assistant #25 stated they entered care plan for Palm Guard (Posey hand roll) on 7/25/24 at 8:29 AM. Occupational Therapy Assistant #25 stated they were asked to assess bilateral hands by a member of nursing team and entered care plans and progress notes after the assessment. They stated they issued Posey hand rolls to the resident and that occupational therapy supervisor would have been responsible for entering the order. Occupational Therapy Assistant #25 stated it was the responsibility of the Unit Supervisor and nursing staff to ensure hand rolls were placed on the resident daily. 2. Resident #54 had diagnoses including anoxic brain injury (lack of oxygen to the brain), dementia, and diabetes. A Quarterly Minimum Data Set (an assessment tool) dated 8/6/24 documented the resident's cognition was severely impaired, and the resident was dependent on staff for activities of daily living. The resident's care plan dated 7/9/24 documented Posey hand rolls to both hands. Interventions included to check skin every shift and as needed and check skin integrity. The Posey rolls could be removed for bathing/dressing/ range of motion, and skin checks. A Physician order dated 7/10/24 documented bilateral Posey hand rolls to increase comfort and limit skin breakdown to palms of hands; to be worn at all times except for hygiene and activities of daily living, and, skin checks. A review of the Treatment Administration Record for August 2024 did not include documentation regarding the hand rolls. A review of the Certified Nurse Aid accountability record August 2024 did not include the need for Posey Hand rolls. During an observation on 08/26/24 at 4:06 PM, the resident's hands were contracted, and the hand rolls were not in place. A hand roll was observed on the bedside table. During observations on 08/27/24 at 10:21 AM and 8/28/24 at 9:01 AM the resident was in bed and did not have Posey rolls in hands. During observations on 08/27/24 at 10:54 AM and 12:56 PM, the resident was in their geriatric chair, there was not a Posey roll in the left hand, and the right hand Posey roll was around the resident's wrist but not positioned in hand. During an observation on 08/28/24 at 12:38 PM the resident was in the dining room being fed by staff and did not have a Posey roll. During an interview on 08/28/24 at 12:38 PM, Physical Therapist #2 stated the resident should be wearing a left hand Posey and did not know why the resident was not wearing it. Physical Therapist #2 stated they were unaware the order was for bilateral Posey rolls. They stated If the resident refused to wear the rolls, the nurses should let them know and the resident would be reassessed. They stated they would also discuss with the physician if the resident was refusing the hand rolls. During an interview on 08/28/24 at 12:42 PM, Certified Nurse Aide #3 stated the resident threw the Posey hand roll at the staff this morning during morning care and they put them away in the bedside drawer. They stated they should have notified the nurse but did not. During an interview on 08/28/24 2:05 PM, Registered Nurse Supervisor #1 stated the Certified Nurse Aide did not notify them that the resident was refusing the Posey hand rolls. If a resident was refusing the hand rolls, they would inform therapy. During an interview on 08/28/24 at 03:04 PM, the Assistant Director of Nursing stated the hand rolls should have been in the Certified Nurse Aide task documentation and did not know why it was not activated on the care plan. They stated if the resident was refusing the hand roll it should have been documented by the nurse and the physician should have been notified. 3. Resident # 91 had a diagnosis of brain damage, chronic respiratory failure, and cardiac arrest. The 6/8/24 admission Minimum Data Set (resident assessment tool) documented the resident had severely impaired cognition and was dependent for other activities of daily living. The 7/10/24 Physician order documented right hand roll to increase comfort and maintain skin integrity. A 7/10/24 care plan documented a right hand roll due increased risk for contractures, and to decrease discomfort in right hand and decrease risk for skin breakdown. A 6/23/24 Certified Nurse Aide Care Card documented right hand roll on, and to remove for skin checks and hygiene. During observations on 8/26/24 at 10:15 AM, 8/27/24 at 10:00 AM, 8/28/24 at 2:00 PM, and 8/29/24 at 9:32 AM, Resident #91 was in bed, the left hand was open and the right hand was in a fist with no hand roll in place. During an interview on 8/30/24 at 10:15 AM, Registered Nurse #8 stated the Rehabilitation Department assessed the resident for the hand roll and when there was an order, nursing was responsible for ensuring the resident used the device. They stated if the resident was not wearing the device, a contracture may get worse or develop an open area. During an interview on 8/30/24 at 10:20 AM, Certified Nurse Aide #9 stated the staff was responsible for putting on the hand roll. They stated it was on the Kardex (care instructions), and they made sure it was on. During an interview on 8/30/24 at 10:30 AM the Director of Rehabilitation stated the Rehab Department was responsible for assessing the resident, providing the equipment and updating the care plan; nursing was responsible for ensuring the equipment was in place. 10 NYCRR 415.12(e)(2) 47626 50766

Based on observations, record review, and interviews conducted during the Recertification Survey and Abbreviated Survey (NY00336677) from (,d+[DATE]-[DATE]), the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety and food prep equipment was clean and in safe operating condition. Specifically, 1) the walk-in refrigerator contained expired peanut butter and jelly sandwiches, and expired egg salad and peanut butter and jelly sandwiches were observed on prepared lunch trays, 2) Resident's personal food was observed in the resident pantry refrigerator beyond its 3 day limit; and 3) the first floor resident ice machine was not clean and observed with black slime on the inside of the machine which was in close contact with ice cubes. The findings are: During an initial tour of the kitchen on [DATE] at 9:28 AM, the walk-in refrigerator was observed with two peanut butter and jelly sandwiches in a large box that were stamped use by [DATE]. A second observation was made on [DATE] 11:46 AM on the food service line of staff preparing the hot meals and placing plates on the food truck preparing for delivery to Resident Units. One egg salad sandwich and 3 more peanut butter and jelly sandwiches stamped use by [DATE] were observed on the trays. During an interview on [DATE] at 12:06 PM with the Assistant Food Service Director they stated the trucks were prepared the day before and lunch meal trays with dry food, cold beverages and sandwiches were put on the trays. They stated they thought that when staff were doing the prep, they mistakenly left sandwiches on the truck dated use by [DATE]. During an interview with the Director of Food Service on [DATE] at 2:16 PM they stated they did not know why expired sandwiches were in the refrigerator and on meal trays but abiding by the use by dates were important because of Infection Control and prevention of illness. The stated food needed to be the freshest and staff just did not think ahead. 2) The facility policy titled Food Brought from Outside, dated [DATE], documented food will be held in the refrigerator for three days following the date on the label and will be discarded by staff upon notification to the resident. An observation was made on the first-floor resident refrigerator on [DATE] at 12:30 PM. Resident food in the refrigerator was dated [DATE] and another package was dated [DATE]. In addition, an undated ice cream cake was observed in the freezer. During an interview on [DATE] 12:52 PM, Licensed Practical Nurse #4 stated residents could keep food in the refrigerator for three days then it would be discarded. The refrigerator was supposed to be checked every day for expired food by Certified Nursing Assistants but did not know why it had not done in a while. 3) On [DATE] at 12:23 PM the lower-level ice machine located in the resident pantry was observed to have a large patch of black slime inside the machine on the right side of the ice tray and on the inside walls of the box. The tray automatically turns on its side when ice is ready and falls down the wall of the machine to the collection unit. The machine was full of ice cubes which fell from ice tray. A dark substance was observed on the bottom of the ice trays. During an interview on [DATE] at 08:35 AM, the Director of Housekeeping stated the Housekeeping Department was responsible for cleaning the ice machines. They stated the last cleaning was [DATE], and was not aware there was a problem, but housekeeping staff should have informed them it had black slime. The Director of Housekeeping stated it was important to keep the ice machines clean since there were a lot of hands going in and out of the machine with each use that could contaminate the ice. 10NYCRR 415.14(h)

Based on record reviews and interviews during the recertification and abbreviated survey (NY00325832) from 8/26/24 to 8/30/24 , the facility did not ensure that a resident's representative was promptly notified of a change in ins status For 1 of 28 residents (Resident #38) reviewed for notification of change. Specifically, Resident #38's designated representative was not made aware the resident had pneumonia and antibiotic was initiated. The findings are: Resident #38 had diagnoses including pneumonia, chronic respiratory failure and dementia. The 8/2/23 Quarterly Minimum Data Set (resident assessment tool) documented the resident had severely impaired cognition and was dependent on staff for all activities of daily living. The 2/25/22 Policy and Procedure titled Notification of Change documented the facility will promptly inform the resident representative when there is a change of condition requiring notification. The 10/8/23 chest x-ray results documents left basilar lung infiltrate (pneumonia). The 10/8/23 physician order documented Cefuroxime (antibiotic) one tablet by gastrostomy tube twice a day for 7 days for pneumonia. Review of the resident's record revealed there was no documented evidence the resident's representative was notified the resident had pneumonia and an antibiotic was initiated. During an interview on 8/30/24 at 10:50 AM, the Director of Nursing stated the nurses were responsible for family notification and it was their expectation that the family would be notified promptly with any changes. During an interview on 8/30/24 at 11:00 AM with Registered Nurse #10 stated they did not remember the incident. The resident's family was very involved and they usually updated them on any changes in the resident's physical condition. Registered Nurse #10 also stated it was the facility's policy to update the family with all changes especially since the resident had a diagnosis of Dementia. 415.3(f)(2)(ii)(b)

Based on observations record review and interviews, during the recertification survey from 8/25/24 to 8/30/24, the facility did not ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner to reflect the resident's changing needs and current status as evidenced by 1 of 4 residents (Resident #24) reviewed for skin impairments. Specifically, Resident #24 acquired a pressure injury on the left heel and the care plan was not updated with goals and interventions to promote wound healing. The findings are: Resident #24 had diagnoses including type 2 diabetes, Alzheimer's disease, and a history of pressure injuries. The Quarterly Minimum Data Set (an assessment tool) dated 7/15/2024 documented Resident # 24 had severe cognitive impairment, was dependent on staff for chair/bed-to-chair transfers and required substantial to maximal assistance for bed mobility and sitting on the side of the bed. Resident #24 was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, had no pressure ulcers/other skin problems (ulcers, wounds), had a pressure reducing device for chair/bed, was on a turning/repositioning program, received nutrition or hydration intervention to manage skin problems, and received ointments/medications other than to feet. The 8/19/2024 Skin Integrity Care Plan documented Resident #24 was at risk for skin breakdown or pressure ulcer injury. The goal was to have no skin breakdown for 90 days. Interventions included turn and position every 2 hours / as needed, monitor skin during daily care, assess for changes in skin condition each shift, and provide incontinent care every 2 hours and as needed. On 8/26/2024 a wound consult secondary to redness of left heel was added to the care plan. The 8/24/2024 Braden Scale (an assessment used to predict a resident's risk of developing pressure sores/ulcers) documented a score of 11 which indicated that resident was at high risk. The 8/24/2024 at 3:18 PM Nurse Practitioner note documented left heel skin changes. Came to resident secondary to family informing the left heel had skin changes. Skin on left heel had redness with some bleeding. Changes in left heel skin integrity, wound consultation. Start zinc oxide. The 8/24/2024 at 3:50 PM Nursing Progress note documented resident in bed, awake, calm not in any distress. Noted with redness on their left heel, seen by Nurse Practitioner with treatment advised, cleansed with normal saline, applied zinc oxide and covered with foam dressing as ordered. Out of bed at lunch time. Plan of care to continue. There was no documented evidence Resident #24's care plans were updated to include interventions for the left heel redness and to prevent the further deterioration of left heel skin integrity. During observation on 08/27/2024 at 9:34 AM Resident #24 was sleeping on their back in a geriatric chair with their heels resting directly on the geriatric chair footrest. The heels were not off-loaded or elevated. During observation on 08/27/2024 at 11:42 AM Resident #24 was resting on their back in a geriatric chair with their ankles crossed and their heels resting directly on the geriatric chair footrest. Heels were not off-loaded and Resident #24 had socks and slippers on. During a continuous observation on 08/28/2024 from 8:50 AM to 11:41 AM Resident #24 was resting on their back with their ankles crossed and heels resting on the footrest. Resident #24 had socks and slippers on and was not turned/repositioned during this time. During an interview on 08/28/2024 at 1:20 PM Resident #24's family member stated they noticed left heel redness during a visit last week and requested staff to look at the heel. The family member was not aware of any interventions put in place except a request for wound consult to take place Friday, August 30, 2024. During observation on 08/29/2024 at 8:35 AM Resident #24 was resting in bed on their back and their heels were not off-loaded. During observation and interview with Registered Nurse #26 on 08/29/2024 at 9:55 AM, Resident # 24's heels were resting on an air mattress and not off-loaded. The left heel was observed with a soiled, white gauze dressing which was removed by Registered Nurse #26. During an immediate interview, Registered Nurse #26 stated it was an unstageable wound and they were not aware why the wound was dressed in white gauze, not in foam dressing as ordered or why heels were not off-loaded. Registered Nurse #26 did not have an explanation when asked what interventions were implemented to prevent further decline of the heel after report of heel redness on 8/24/2024. During observation and interview on 08/29/2024 at 11:59 AM Nurse Practitioner #27 stated the left heel wound was unstageable and had progressed from heel redness which was reported 8/24/2024. Nurse Practitioner #27 stated nurse judgement should have been applied and heel off-loading, turning and repositioning and heel boots should have been added to the care plan immediately upon report of heel redness. During interview and observation on 08/30/2024 at 9:15 AM Wound Consultant Nurse Practitioner stated the left heel wound was unstageable. They stated pressure ulcer preventative measures could have been put in place when redness was reported on 8/24/2024 including skin prep, heel booties, off-loading, elevating feet, turning and repositioning every two hours. The staff could have taken a picture and sent it to them, and they could have made a referral to physical therapy and occupational therapy to address the resident crossing their legs and for assistive devices. During interview on 8/30/2024 at 12:03 PM the Director of Nursing stated when a change in skin integrity is reported, the resident should be assessed by the unit registered nurse and an assessment requested from the facility nurse practitioner. Once registered nurse assessment is completed, registered nurse should enter care plans, document notes, notify family of changes and plan of care. Director of Nursing stated interventions should be started immediately based on nursing judgement and orders. Interventions include off-loading, turning and repositioning, resident taken out of bed for period of time, personal hygiene, nutrition review for supplements, supportive devices including cushions, heel boots, hand rolls and possibly, x-rays. Labs including albumin should be ordered. Director of Nursing stated residents at risk for pressure ulcers should be assessed for devices such as chair cushions, heel booties and hand rolls. During interview on 08/30/2024 at 1:30 PM the Medical Director stated the expectation for residents who were at risk for pressure ulcers, included off-loading to begin immediately, turning and repositioning every two hours, efforts to minimize skin excoriation by changing residents frequently, booties used if applicable, and skin barrier ointment. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during a Recertification Survey (8/26/24-8/30/24), the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, 1) the facility did not ensure that an infection surveillance plan based on facility assessment was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks. 2) the facility Water Management Plan for Legionella had not been reviewed annually, 3) the facility did not ensure that 9 of 10 staff members were offered and educated regarding the risks and benefits of the pneumonia vaccination and given the opportunity to decline or receive the vaccination; and 4) did not properly implement Enhanced Barrier Precautions for 4 of 24 residents ( #6,#307,#309 and #24). The findings are: 1) The infection tracking logs documented infections that were being tracked for the month of July 2024. There was no documentation during July 2024, August 2024 that could be reviewed for infection onset dates, signs and symptoms, lab tests/results, isolation, and outbreak potential. During an interview on 08/28/24 at 10:43 AM with the Infection Preventionist who stated the line list of infections for June was not found and August line list was not done yet but will be doing it soon since it is done at the end of the month. The Infection Preventionist does not track infections as they are happening and currently did not know if there were any patterns of infections occurring to identify and prevent the spread of further infections. During an interview with the Director of Nursing on 8/28/24 at 12:25 PM they stated they did not have a tool to document infection tracking and knows about the different infections in morning report. The Infection Preventionist is supposed to be taking notes of the infections in real time because that is part of their Infection Preventionist job. The Director of Nursing stated this needs to be done to catch a cluster of infections to prevent them from spreading. 2)The Water Management Plan for Legionella prevention was reviewed and dated December 2016 and there was no documentation the plan was reviewed and if needed revised annually. During an interview with the Director of Maintenance on 8/26/2024 they stated they were aware the plan needed to be reviewed and updated yearly for accuracy but did not realize it had been since 2016. 3) A review of the immunization records of 7 out of 10 randomly selected employees (#22 #33,#34, #35, #36, #37, #38) indicated that education regarding the risks and benefits of pneumonia vaccination was not provided. There was no documented evidence that the vaccine was offered and/or received or that the employees declined to receive the vaccination and were provided education. During an interview with the Infection Preventionist on 08/27/24 at 02:40 PM they stated they don't offer the pneumococcal routinely because no one wants it but did not have declinations from staff to review. During an interview with the Director of Nursing on 08/30/24 01:58 PM they stated the Infection Preventionist should be keeping track of vaccines and does not know why it is so disorganized. 4) Resident #307 had diagnoses of anemia, dementia, and dysphagia. The physician orders dated 5/30/24 documented Enhanced Barrier Precautions for heel wound and right hip surgical wound. Resident#309 had diagnosis of anemia, dementia, and hypertension. The physician's orders dated 8/26/24 documented Enhanced Barrier Precautions for surgical wound. During an observation and interview with the Infection Preventionist on 8/28/24 at 10:43 AM on the first-floor unit, Resident #307 and Resident #309 rooms were viewed. There were no doffing pails and no supply carts in the hallway for easy accessibility. The Infection Preventionist stated carts need to be conveniently located outside the resident's rooms, so staff are not walking around in the hallway looking for additional supplies. The Infection Preventionist stated they did not know why this was not done but it should be in place. 10NYCRR 415.19(a)(2) 50766

Based on record review and interview during the recertification survey conducted 08/26/24 to 08/30/24, the facility did not ensure each resident was offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 1 of 5 residents (Residents #91) reviewed. Specifically, there was no documented evidence Resident #91 was offered, declined, or educated on the pneumococcal immunization. Findings include: The undated facility policy titled Resident Pneumovax Vaccination Program, documented the Pneumovax is to be given to all residents who have no prior evidence of receiving it. All new admissions are to be assessed for the need for this vaccine as part of the admission medical work up. Residents will be provided with instruction and education relative to Pneumovax and aspects of our vaccination program. The education will be given on admissions as well as prior to the implementation of our immunization program and may consist of fliers and fact sheets. All education will be documented on the Resident Consent /Declination form in the comprehensive care plan and or nurse's notes for validation. Resident #91 had diagnoses of respiratory failure, seizures and was ventilator dependent. There was no documented evidence that the resident/resident representative received education, was offered the vaccination, or declined the pneumococcal vaccine. During an interview on 08/28/24 at 12:05 PM, with the Infection Preventionist they stated vaccines for residents was important because they provided good protection against disease for residents. There was not one person in charge of obtaining vaccine information for the residents and left it up to the Nursing Supervisors to get consents and write notes. The Infection Preventionist had no tool with Resident information and vaccine status and did not know which residents were eligible, declined or were provided education about pneumococcal vaccine. The Infection Preventionist stated they did not keep a record of declinations from residents and/or residents representative. During an interview with the Director of Nursing on 08/30/24 at 1:58 PM, they stated the Infection Preventionist should be keeping track of vaccines for residents and staff and did not know why it was so disorganized. The Director of Nursing stated they needed to track vaccine status better. 10NYCRR 415.19 (a) (1-3)

Based on interview and record review during the recertification survey conducted 08/26/24-8/30/24, the facility did not ensure each staff and resident was screened, offered the COVID-19 vaccine and provided education regarding the benefits, risks and potential side effects associated with the vaccine for 1 of 5 residents and 1 of 10 staff reviewed for COVID vaccines. Specifically, there was no documented evidence of immunization records for COVID vaccines for Resident #91 and Staff #37. Findings include: The facility policy titled COVID-19 Vaccination for Residents and Staff and last revised 5/13/21 documents in order to prevent the spread of infectious disease and to decrease the morbidity and mortality associated with the SARS-Co V-2 virus the facility will offer vaccine to all residents and residents/resident representatives will be provided education. Resident #91 had diagnoses of respiratory failure, seizures and was ventilator dependent. There was no documented evidence that the resident/resident representative received education, was offered the vaccination, or declined the COVID vaccine. During the recertification survey the facility was asked to provide the vaccination status for flu, pneumococcal and COVID vaccines. There was no documented evidence the facility had documentation of screening, education offering or current COVID19 status for Resident #91and Staff #37. During an interview with Infection Preventionist on 08/27/24 at 2:40 PM, they stated they dealt with the vaccines that were given in facility, but the ones given outside were kept in a separate binder. The current Staff and Resident files were not in order. The Infection Preventionist stated they did not have records of staff or residents who were offered, declined, and were educated on COVID vaccines. They stated they did not keep track or follow up with staff who had not provided their vaccine history and did not think Staff #37 workedat the facility. During an interview with the Registered Nurse Supervisor #22 on 08/28/24 at 10:22 AM, they stated when a new admission resident came into the facility, they would look up vaccine information in their record and whatever was missing they would pass on to the next supervisor. They stated there was no way to keep track or follow up on it as it just gets passed down to the next person. During an interview with Respiratory Therapist #37 on 08/30/24 at 01:30 PM, they stated they worked per diem roughly once a week for the past two years and brought their supervisor their vaccine records. They stated they had not been approached by the Infection Preventionist about their vaccine status or offered any additional vaccines during that time. During an interview with Certified Nurses Aide #39 on 8/28/24 at 10:28 AM, they stated they had been at the facility for 2 years and had not been offered the current COVID booster vaccine. During an interview with Certified Nurses Aide #40 on 08/30/24 at 10:11 AM, they stated they had the original COVID series of 2 vaccines but had not been offered a booster at the facility. 10NYCRR 415.19 (a)(1-3)

Based on record review and interviews conducted during an abbreviated survey (NY00322720), the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accident hazards as possible for 1 of 3 residents (Resident #1) reviewed. Specifically, on 08/24/2023 Certified Nursing Assistant (CNA#5) provided care to Resident #1 who required 2-person assistance for toileting and bed mobility, by themselves without assistance. Resident #1 rolled out of bed and fell sustaining a right tibia and fibula (shin/calf bone) fracture. The findings are: The Facility Policy and Procedure on Accident Policy revision date 2/23/2017 documented to promote an environment that is free from accidents or hazards as is possible, and each resident receives adequate supervision. Fall refers to unintentionally coming to rest on the ground, floor or other lower levels, but not as a result of an overwhelming force (i.e., resident pushes another resident). Resident #1 had diagnoses that included atrial fibrillation, chronic obstructive pulmonary disorder (COPD), chronic lymphedema and chronic idiopathic thrombocytopenia. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 04/14/2023, documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 12/15, associated with moderate cognitive impairment. Resident #1 was non ambulatory and used a wheelchair. Resident #1 required extensive assistance of 2 with bed mobility, locomotion on/off unit, toileting, and personal hygiene. Two-person assist with transfers. The Fall Risk Assessment initiated on 08/24/2023 and reviewed on 11/08/2023 documented that the resident scored 16 denoting low risk for fall. Resident #1's Nursing Instructions from 08/01/2023 to 08/31/2023 documented that the resident required extensive two-person physical assistance for transfer, locomotion on the unit, and bed-mobility. Review of the Fall/Injury Care Plan initiated on 02/06/2022 and last revised on 07/03/2023 documented that the resident required assistance with ADL care including assistance with transfers. Resident is non ambulatory. Goals are to have no falls related to unsteady gait or orthostatic hypotension, maintain safe environment as evidenced by no falls for 90 day and be without injury form falls for 90 days. Interventions are to anticipate needs of resident and toilet use with appropriate staff assistance. Review of the Facility Accident / Incident (A/I) Report dated 08/24/2023 documented that Resident #1 who was a two-person assist with toileting and turning fell on the floor during care when CNA #5 attempted to render care without assistance. Resident #1 complained of pain and was transferred to the hospital where it was determined by X-rays taken on 08/24/2023 that the resident sustained a fractured right tibia and fibula (shin and calf bone) from the fall. Review of CNA #5's written statement documented that on 08/24/2023 at 6:30 AM they went into residents' room to provide morning care, after washing resident perineal area they turned resident to the left side to remove their brief. Resident rolled off the bed onto the floor. CNA stated they yelled for help and the Licensed Practical Nurse (LPN #1) came into room. Emergency Medical Service (EMS) was called, and resident was transferred to the hospital. Review of LPN #1 written statement documented that on 08/24/2023 at 6:30 AM the resident was observed on right side lying on the floor at the left side of the bed. As per CNA #5, the resident rolled out of bed when they were turning on left side to change the brief. Resident complained of pain on right hip and right leg. Resident refused further assessment because of pain and physician notified. Resident was transported by ambulance to the hospital for further evaluation. During an interview conducted with Registered Nurse (RN #1) on 11/08/2023 at 2:52 PM, the RN stated that if a resident is a two person assist staff must follow protocol. RN #1 stated that residents plan of care is very important to follow to render proper care. During an interview conducted with Administrator on 11/08/2023 at 3:17 PM, the Administrator stated that they expect staff to follow care instructions and CNA #5 should have asked for assistance from the nurse or other staff on duty. Administrator stated all staff were reeducated on plan of care and ADL. The administrator stated CNA #5 failed to follow plan of care and was suspended. During an interview conducted with Director of Nursing (DON) on 11/08/2023 at 3:22 PM, the DON stated that CNA #5 was aware that Resident #1 needed two people to render care and repositioning. The DON stated that all CNAs must follow Kardex instructions and the plan of care for each resident. The DON stated that competency training was completed for all nursing staff. The DON stated that CNA # 5 was suspended and reeducated before returning on duty. During a telephone interview conducted with CNA #5 11/28/2023 at 2:10 PM, CNA #5 stated the resident was a two person assist and they were aware of this because they verified from the Certified Nurse Instructions. CNA #5 stated the other aide was providing care with someone else. CNA #5 stated when they were turning the resident to give peri care the resident slipped off the bed onto the side. CNA #5 stated normally they would not have completed care but this night the other aide was busy. CNA #5 stated it was just two people working the hall. CNA #5 stated they didn't ask the nurse for help because they were just turning the resident and didn't think they would need help. CNA #5 stated they yelled for the nurse when the resident fell on the floor, the nurse came right away. CNA #5 stated they were suspended one day, and training/education was initiated. CNA #5 stated they learned not to complete two persons assist without assistance. 483.12(a)(1)

Based on record review and interviews during an abbreviated survey (NY 050), the facility did not ensure that the resident representative was notified of a change in condition for 1 (Resident #1) of 4 residents reviewed for notification of changes. Specifically, the facility did not notify Resident # 1's representative when they began the removal process and finally removed resident's [CONDITION(S)]. The findings are: The Policy and Procedure (P&P) titled Notification of Change undated, documented it is the policy of the facility to immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident or incident involving the resident, upon significant change in status or condition or regarding changed in residents' rights. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 05/29/2021 documented that the resident had severe cognition impairment. Review of a Respiratory Clinical Progress Note dated 04/17/2021 at 9:41 AM documented that Resident #1 is comfortable on room air and will consider capping. Review of a Respiratory Clinical Progress Note dated 04/19/2021 at 10:13 AM documented that Resident #1's [CONDITION(S)] was closed with a [CONDITION(S)] button. A Social Service Progress Note dated 04/30/2021 at 12:06 AM, documented that Resident #1 was no longer in need of the respiratory unit. Resident #1 had been weaned off the vent and the [CONDITION(S)] Review of the resident electronic medical record revealed no documentation of the resident representative having been notified of the changes regarding Resident #1's [CONDITION(S)]. During an interview conducted on 11/09/2022 at 9:30 AM, Resident #1 POA stated they had a video call with Resident #1 around 4/23/2021 and Resident #1 showed them their neck. Resident #1's POA stated that was when they saw the [CONDITION(S)] had been removed. Resident #1's POA stated they received a call from an individual from the facility who removed the [CONDITION(S)], but the POA could not remember the staf's name. POA stated the individual informed them that they did not have to notify them about removing the [CONDITION(S)]. In a follow up interview with the POA conducted on 11/16/2022 at 3:09 PM, the POA stated they could not recall the exact date of the video call with Resident #1 but they believed it was the week of the April 23, 2021. Resident #1's POA stated they had a care plan meeting after the [CONDITION(S)] had been removed. During an interview conducted on 11/09/22 at 10:42 AM, the Respiratory Therapy Director (RTD) stated they were responsible for removing Resident #1's [CONDITION(S)]. The RTD stated the family is usually informed of a [CONDITION(S)] being removed during care plan meetings. The RTD stated if the family were not notified during the meeting, the respiratory staff will notify the nurse supervisor who will then notify the family. The RTD stated they did not remember notifying the family personally and stated they did not document any communication in Resident #1's health record. RTD stated Resident #1's family came to visit the resident frequently and he/she [NAME] the family was informed but could not be certain if it was communicated or not. During an interview conducted on 11/09/2022 at 12:45 PM, the Registered Nurse (RN) Nurse Supervisor stated residents and/or their representatives are to be notified for any change or condition, any incidents, changed in medication or for anything that is not current. The RN Supervisor stated any nurse who is in on the floor the day of the incident or change is responsible for making notification. The RN Supervisor stated anyone can notify a representative of a change in condition and normally it is documented in the record. The RN Supervisor stated sometimes the representative may be notified in person, but the communication should still be documented in the health record. RN Supervisor stated the Nurse, or the Respiratory therapist should have notified Resident #1's family of the [CONDITION(S)] being removed, and it should have been documented. 513.3(e)(2)(ii)(b)

Based on interview and record review conducted during the abbreviated survey (NY 1785), the facility did not ensure that a resident was free from significant medication errors for 1 of 3 residents reviewed. Specifically, the facility did not ensure that a significant medication was accurately transcribed from Hospital Discharge Instructions for Resident #1. Subsequently, Resident #1 did not receive [MEDICATION(S)] (for nerve pain) 300 mg, 2 capsules by mouth 3 times a day (a total of 600 mg 3 times a day). Instead, Resident #1 received [MEDICATION(S)] 300 mg, 1 capsule, 3 times a day (a total of 300 mg 3 times a day), from 12/01/2021 through 12/07/2021, which was half the dose of [MEDICATION(S)] that s/he should have received. The finding is: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS; an assessment tool) dated 12/06/2021 documented that resident has a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 7/15 associated with severe cognitive impairment. The resident required extensive assistance for activities of daily living and received scheduled and PRN (as needed) pain medication and reported pain of 4 on a scale of 0-10. Review of the facility policy titled admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders will be electronically sent to the pharmacy, the Registered Nurse (RN) transcribes the orders to the Electronic Medical Record (EMAR), and the incoming shift will review the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility policy titled Medication Order Transcription effective 12/2020 documented the physician's medication orders will be accurately transcribed and executed in a timely manner. Nurses on all shifts must review and countersign all medication orders. This is applicable to monthly and interim orders Review of the Care Plan titled Alteration in Endocrine Metabolic Status, related to Prediabetes and [CONDITION(S)], dated 12/03/2021, documented the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan titled Alteration in Neurological Status, dated 12/03/2021, documented interventions including to administer medications as ordered, monitor effectiveness and side effects. Review of the Hospital Discharge Summary dated 11/30/2021 with instructions to continue Discharge Medications which included [MEDICATION(S)] 300 mg, 2 capsules by mouth 3 times a day. Review of a Nurse Practitioner (NP) Admission note dated 12/01/2021 documented the resident was admitted to hospital for complaints of neck pain, CT cervical spine shows anterolisthesis of C-7-T-1. Past Medical History including [CONDITION(S)], [CONDITION(S)] left shoulder. Plan to continue [MEDICATION(S)] for [CONDITION(S)]. Review of an RN Nursing Admission note dated 12/01/2021 documents resident admitted for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician's orders dated 11/30/2021 documents [MEDICATION(S)] 300 mg, 1 capsule 3 times per day for [CONDITION(S)]. Review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No admission medications audit was made available, despite several requests for the document. During an interview conducted with RN#1 on 8/25/2022 at 1:45 PM, RN#1 stated s/he entered the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated s/he called the Physician and read the medications on the hospital discharge list and entered the orders into the resident's EMAR. RN#1 stated s/he doesn't remember whether the Physician told her to order only 1 capsule instead of 2 capsules. The RN stated that if the Physician had ordered 1 capsule of [MEDICATION(S)] instead of 2 capsules of [MEDICATION(S)], s/he would have written a Nurse's note documenting the order clarification regarding the [MEDICATION(S)] dosage. During an interview conducted with RN Unit Manager (RNUM) on 8/25/2022 at 1:55 PM, the RNUM stated that the admission nurse is responsible to review the hospital discharge medication list with the ordering Physician and place the orders according to the Physician. During an interview conducted with the Director of Nursing (DON) on 8/25/2022 at 2:00 PM, the DON stated that on admission, the nurse should review the hospital discharge medication list with the Physician, and the Physician either agrees or disagrees with the medications, and the nurse places the orders from the Physician. The DON stated that the nurse on the next shift should reconcile the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted with the ordering Physician on 8/25/2022 at 2:25 PM, the physician stated s/he usually carries out the hospital discharge orders without making changes and would only change the orders after admission if there were any noted side effects. During an interview conducted with the consulting Pharmacist on 8/26/2022 at 10:00 AM, the pharmacist stated that on admission, the pharmacist reviews the physician's orders after they are written and checks the indication or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted with the RN Supervisor (RNS#2) on 8/26/2022 at 12:20 PM, the RNS stated s/he worked the 11-7 shift on 11/30/2021. RNS#2 stated that the medication nurse working on the unit the shift after the resident was admitted should reconcile the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RNS#2 stated there is no paper audit form available to assure reconciliation was completed. The RNS stated that if the nurse notices the discrepancy, they will notify the RNS, and the RNS would follow-up with the Physician. On 8/26/2022, multiple attempts were made throughout the day to contact the medication nurse who worked the 11-7 shift on 11/30/2021, with no result. During an interview conducted with RN #2 on 9/14/2022, RN#2 stated s/he was the nurse who worked the 7-3 shift on December 1st. RN#2 stated they usually reconcile the facility orders against the hospital discharge medication list for newly admitted residents to be sure the orders are correct, and s/he does not know if s/he forgot to do so or if s/he missed the medication order error in this case. 415.12(m)(2)