Every finding on record at Beechwood Health Care Center, Inc.

Based on interview and record review conducted during a Complaint investigation (#NY00383549) the facility did not ensure that residents are free of significant medication errors for one (1) (Resident #1) of three (3) residents reviewed. Specifically, on 06/11/2025 Licensed Practical Nurse #1 erroneously administered Resident #2's morning medications to Resident #1 which resulted in a significant medication error.The finding is:The policy and procedure titled Medication Administration effective 05/11/2023 documented medications shall be administered in accordance with established procedures including right resident, right medication, right dose, right time, right route, right reason, and right documentation.Resident #1 had diagnoses including cerebrovascular disease (group of conditions that affect blood flow to the brain), vascular dementia (dementia caused by brain damage from impaired blood flow), and hypertension. The Minimum Data Set (a resident assessment tool) dated 05/16/2025 documented Resident #1 was cognitively intact and received medications including but not limited to antipsychotic (medication used to treat psychosis), antidepressant, and antiplatelet (medication used to prevent blood clots).Resident #2 had diagnoses including congestive heart failure, hypertension (high blood pressure), and edema (swelling). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and received medications including but not limited to anticonvulsant (medication used to treat seizures), diuretic (used to treat edema), and opioid (narcotic pain reliever).Resident #2 Physician orders included gabapentin 400 milligrams twice a day by mouth for neuropathy, nerve pain, (date initiated 12/10/2024). Oxycontin ER (extended release) 15 milligrams every twelve hours by mouth for pain (date initiated 06/01/2025), bumetanide 1 milligram once a day by mouth for fluid retention (date initiated 12/05/2024), Entresto 24-26 milligrams twice a day by mouth for congestive heart failure (date initiated 12/05/2024), and Flomax 0.4 milligrams twice a day by mouth for benign prostatic hyperplasia, enlarged prostate, (date initiated 12/05/2024). The facility Medication Error Report dated 06/11/2025 documented a medication error was made by Licensed Practical Nurse #1 involving Resident #1. Licensed Practical Nurse #1 administered medications including but not limited to gabapentin (used to treat seizures, nerve pain, and restless leg syndrome), oxycontin ER (extended release/narcotic pain reliever), bumetanide (used to treat edema), Entresto (used to treat chronic heart failure), and Flomax (used to relax muscles in the bladder) to the wrong resident. The Medical Director was notified and gave new orders to monitor vital signs every two hours for eight hours then every shift for twenty-four hours and monitor for adverse effects.Resident #1 exhibited low blood pressure and lethargy after the medication administration. The Medical Director was updated 6/11/2025, and new orders were received to hold scheduled 12:00 PM and 2:00 PM medications, insert peripheral intravenous device (thin flexible tube used to administer fluids directly in to a vein) and start 0.9% normal saline at 100 ml (milliliters) per hour for a total of one liter (1000 milliliters), and apply thigh high thrombo-embolus deterrent stockings (specially designed stockings to help reduce the risk of developing a blood clot in lower extremity). During an interview on 07/03/2025 at 9:27 AM, Licensed Practical Nurse #1 stated they started a medication pass and poured medications for another resident (#2). They stated they became distracted during the medication pass by another resident and then a residents family member. Licensed Practical Nurse #1 stated they mistakenly administered another resident's (#2) medications to Resident #1 and reported the error immediately upon identification of the error. During an interview on 07/03/2025 at 10:07 AM, the Director of Nursing stated Resident #1 received Resident #2's' medications, including cardiac medications; and would consider the error a significant medication error. Additionally, the Director of Nursing stated the Medical Director was notified and when the resident started to exhibit low blood pressure and lethargy, intravenous fluids were administered to prevent dehydration.During an interview on 07/02/2025 at 10:57 AM, the Medical Director stated they expected the seven rights of medication administration to be followed by all nurses and medications be administered to the correct resident. Additionally, the Medical Director stated the medications Resident #1 received in error were important medications but had a mild and short-term impact on the resident, and the intravenous fluids were given as a precaution to avoid dehydration and hospitalization. 10 NYCRR 415.12(m)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/8/23, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (Resident #6 and #66) of seven residents reviewed for quality of care related to accidents and positioning. Specifically, there was lack of assessments and monitoring for Resident #6 after they spilled coffee on themselves, and Resident #66 was not provided with leg rests while they were in their wheelchair. Additionally, while sitting in their wheelchair, Resident #66's feet were hanging down and were approximately six inches from touching the floor for extended periods of time. The findings are: The policy and procedure (P&P) titled Positioning - Chair/Bed dated 8/29/2018 documented adaptations to the wheelchair are provided as needed and noted in the electronic medical record (EMR). Additionally, the P&P documented, if the resident's condition and need for wheelchair changes, the rehabilitation department is notified, and an evaluation will be completed. Appropriate changes will be made and documented on the resident Kardex (a guide used by staff to provide care)/care plan. Follow up nursing education will be completed based on resident need and condition to maintain safety and optimal functional level. The P&P titled Resident Accident and Incident Reporting dated 1/24/22 documented all resident accidents and incidents were reported to ensure that the residents receive appropriate intervention and care plan updates. The nurse documents the occurrence and necessary treatment in the nurse's notes. 1. Resident #66 was admitted with diagnoses dementia, osteoarthritis (a type of arthritis that causes pain and stiffness in joints), and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 10/19/2023 documented Resident #66 was rarely understood, rarely understands and was severely cognitively impaired. The Comprehensive Care Plan (CCP) dated 10/11/2023 documented Resident #66 was at risk for alteration in positioning related to diagnosis of Alzheimer's dementia. Interventions included: for transport and meals only: high back wheelchair (a wheelchair with a higher back than a standard wheelchair) with anti-thrust cushion (a type of cushion with a higher front surface and lower back surface to prevent sliding) with gel overlay on top and bilateral leg rests. The Kardex (guide used by staff to provide care) dated 11/6/23 documented Resident #66 required for transport and meals only: high back wheelchair with anti-thrust cushion with gel overlay on top and bilateral leg rests. During a continuous observation on 11/6/23 from 9:13 AM until 12:14 PM, Resident #66 was sitting in their wheelchair with their feet dangling unsupported. Resident #66 was sitting in their wheelchair holding on to a table and rocking back and forth. Resident #66's wheelchair did not have leg/footrests and Resident #66's feet were unable to touch the floor. At 9:35 AM, Certified Nursing Assistant (CNA) #1 wheeled Resident #66 to the lounge area. Resident #66 sat in their wheelchair in the lounge area; their feet dangled, unsupported and did not touch the floor (approximately six inches from the floor). Resident #66 continued to rock in their wheelchair. At 12:00 PM, Resident #66 was wheeled back to the dining room. Staff did not attempt to put leg rests/foot support on Resident #66's wheelchair throughout the observation. During a continuous observation on 11/7/23 from 8:00 AM through 10:31 AM, Resident #66 was sitting in their wheelchair with their feet dangling unsupported. Resident #66 was sitting in their wheelchair in the dining room and occasionally rocking back and forth. Resident #66's feet were unable to reach the floor and were approximately six inches from the floor. At times, Resident #66 would move their feet and point their toes downwards. At 10:31 AM, CNA #1 wheeled Resident #66 to the lounge. CNA #1 and CNA #2 transferred Resident #66 to a reclining chair in the lounge area. CNA #1 elevated the leg rests of the reclining chair. Resident #66 placed their feet flat on the leg rest of the reclining chair. During an interview on 11/7/23 at 12:45 PM, CNA #2 stated they checked the Kardex at least once a week because the Kardex could change. CNA #2 stated Resident #66 was dependent on the staff for care. CNA #2 stated they were not sure if Resident #66's feet could touch the floor while they were seated in their wheelchair because Resident #66 was fidgety. CNA #2 stated they did not know when the last time Resident #66 had leg rests on their wheelchair and they could have been misplaced. During an interview on 11/7/23 at 12:52 PM, CNA #1 stated Resident #66's feet were able to touch the floor when Resident #66 was in their wheelchair. CNA #1 stated Resident #66 was not supposed to have leg rests on their wheelchair. CNA #1 stated they checked the Kardex every morning. During an observation on 11/7/23 at 1:01 PM, CNA #1 and CNA #2 transferred Resident #66 into their wheelchair. Resident #66's wheelchair had a cushion in it that had a dip towards the back and was raised approximately 2-3 in the front. When Resident #66 sat in their chair, their feet did not touch the floor and were approximately six inches from the floor. CNA #1 and CNA #2 stated Resident #66's feet did not touch the floor. During an interview on 11/7/23 at 1:03 PM, Occupational Therapist (OT) #1 stated, Oh Resident #66 has foot pedals. OT #1 stated, usually Resident #66 was only in their wheelchair for meals and would have pedals on the wheelchair at that time. OT #1 stated Resident #66 would have the potential for foot drop if they were in the wheelchair for an extended time without the pedals. OT #1 stated Resident #66 was very active so they were not sure how long it would take for foot drop to develop. OT #1 stated they were going to go get new foot pedals for Resident #66. During an interview on 11/7/23 at 1:06 PM, Registered Nurse (RN) #1 stated they expected the CNAs to check the Kardex every day for new recommendations and they should follow the recommendations on the Kardex. RN #1 stated it would not be comfortable for Resident #66 to sit for a long period of time without their feet touching the floor or foot pedals. During an interview on 11/8/23 at 10:40 AM, OT #2 stated residents were screened at least four times a year and with any referrals from nursing. OT #2 stated Occupational Therapy was responsible for wheelchair positioning. OT #2 stated Resident #66 had a lot of movement that they considered sensory movement. OT #2 stated an antithrust cushion was added to Resident #66's wheelchair on 10/6/23 to prevent Resident #66 from sliding and Resident #66 had better positioning with the antithrust cushion in their wheelchair. OT #2 stated there should have been foot pedals on Resident #66's wheelchair for foot support. OT #2 stated Resident #66 could potentially have discomfort without the foot pedals. During an interview on 11/8/23 at 10:47 AM, OT #1 stated they usually see Resident #66 during meals, and they have never checked under the dining room table to see if Resident #66 had their foot pedals on the wheelchair. OT #1 stated therapy made the recommendations, and it was expected that nursing follows the recommendations. OT #1 stated if it was noticed the recommendations were not followed, then they would intervene. OT #1 stated Resident #66 could not verbalize when they had pain, but in the past, they either pointed or tapped where they had pain. OT #1 stated, We would hope Resident #66 would point or something to tell us if they were hurting. OT #1 stated they would encourage the use of foot pedals when in the wheelchair for overall security, to keep the feet from dragging and to promote alignment and upright positioning. During a telephone interview on 11/8/23 at 11:22 AM, Hospice RN #2 stated they were concerned about the length of time Resident #66 sat in their wheelchair with their feet hanging down without any support. RN #2 stated they considered that a positioning problem and there was a possibility that Resident #66 had discomfort. During an interview on 11/8/23 at 12:05 PM, the Director of Nursing (DON) stated if it was care planned, it was expected the staff put leg rests on the wheelchair. DON stated the feet should be supported for comfort and to prevent dependent edema. DON stated the CNAs were responsible to look at the Kardex every day. DON stated the nurses on the unit should make sure the CNAs were looking at the Kardex and following it. 2. Resident #6 had diagnoses including depression, muscle weakness, and post-polio syndrome (a group of potentially disabling symptoms that appear decades after a polio infection). The MDS dated [DATE] documented the Resident #6 had moderate cognitive impairment. The Kardex dated 11/8/23 documented Resident #6 needed set up assistance for eating. The CCP dated 9/27/23 documented Resident #6 was at risk for alteration in feeding related to their diagnosis of post-polio syndrome. Interventions included mugs for soups and set up assistance for eating. During a lunch observation on 11/2/23 at 12:35 PM, Resident #6 was seated at a table in the unit dining area and spilled coffee on their lap. The lid on the disposable cup was not secured. Review of the nursing Progress Notes dated 11/2/23 revealed there was no assessment or monitoring of the resident's skin. Review of the Buffalo House report sheets dated 11/2/23-11/3/23 revealed there was no documentation that Resident #6 was assessed or monitored after the coffee spill. During an interview on 11/7/23 at 9:44 AM, CNA #3 stated they remembered Resident #6 spilled coffee on themselves last Thursday (11/2). CNA #3 stated they saw the resident patting themselves off, so they went over to the resident and noticed they had liquid on their clothing. CNA #3 stated the lid for the coffee cup wasn't on all the way and the resident must have spilled it on themselves. CNA #3 stated they reported it to the nurse, they weren't sure their name but thought it was the nurse working today (Licensed Practical Nurse (LPN) #1). During an interview on 11/7/23 at 12:09 PM, LPN #1 stated they left early that day (11/2/23) and didn't recall Resident #6 spilling their coffee on themselves and that nobody reported anything to them. During an interview on 11/7/23 at 12:07 PM, LPN #2 stated they worked on 11/2/23 and at lunch time they stayed on their side during lunch and did not know anything about a resident that spilled coffee on themselves. During an interview on 11/7/23 at 12:51 PM, Registered Nurse (RN) Unit Manager (UM) #3 stated if a resident spilled coffee on themselves there would usually be a note about the skin and to monitor the resident. During a telephone interview on 11/8/23 at 8:56 AM, LPN #1 stated they would expect the CNAs to tell them if a resident spilled coffee on themselves and they would have checked the resident, documented it, and told the supervisor. LPN #1 stated they were not in the dining area on 11/2/23. During an interview on 11/8/23 at 11:04 AM, the Director of Nursing (DON) stated they would consider this an accident and the staff should have told the nurse. There was a miscommunication between the CNAs where each thought the other told the nurse about the spill. The resident should have been assessed for redness and put on report to monitor for any delayed injury or if blister formed. The DON stated for hot drink spills they would fill out and incident report as there was potential for a burn. The DON stated when they found out about this yesterday, they had Occupational Therapy (OT) look at the resident which was routine for any spill during meal. The DON stated the nurse should have been in the dining room during meals to monitor the residents. During a telephone interview on 11/8/23 at 1:24 PM, CNA #4 stated when they were passing lunch trays (on 11/2/23), CNA #3 asked Resident #6 if they were ok, so CNA #4 went to see what happened. CNA #4 stated they didn't tell the nurse because they thought CNA #3 told the nurse. CNA #4 stated they didn't know if the nurse was on the floor when this happened and it was something that normally was reported to the nurse. 10NYCRR 415.12

Based on observation, interview and record review conducted during the Standard survey completed on 1/14/22, the facility did not store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for two of two medication storage cabinets ([NAME] and [NAME] Units) observed for safe medication storage. Specifically, two medication cabinets located in common areas were observed unlocked with over-the-counter medication bottles ([NAME] and [NAME] Units) and one medication cabinet contained 21 prescription blister packs and two prescription nebulizer (inhaled) medications ([NAME] Unit). The finding is: 1. Review of the facility policy titled Medications Administering-Equipment & Supplies effective 1/8/09 revealed the facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications include: Lockable medication carts and medication cabinets, drawers or rooms with well-lit dose preparation areas. a. During an observation on 1/12/22 at 7:53 AM on the [NAME] Unit, the medication storage cabinet located in the common area near the resident dining room was observed unlocked and unattended by staff. At 7:54 AM Registered Nurse (RN) #4 stated they had the medication cabinet keys and the medication cabinets were to be locked at all times when not attended by a nurse. RN #4 also stated they had just retrieved medications from the cabinet and did not lock it. On 1/12/22 at 7:57 AM, RN #4 was observed to walk away from the unlocked medication cabinet to answer a call light. During an observation from 7:57 AM until 8:03 AM the medication cabinet was unlocked and no facility staff was in the area. During another observation at 8:18 AM, the medication cabinet was unlocked and unattended. During an interview on 1/12/22 at 9:32 AM, RN #4 stated they broke the key in the cabinet door, called maintenance to fix it, and should have maintained the medication cabinet within visual sight to ensure residents and others did not have access to the medications. Observation on 1/12/22 at 9:32 AM, in the presence of RN #4 and RN #5 revealed the following over-the-counter medications were located in the [NAME] Unit medication cabinet: · Aspirin 325 milligram (mg) 2 bottles, 100 tablets each · [MEDICATION(S)] Coated Aspirin 325 mg 2 bottles, 100 tablets each · Aspirin chewable 81 mg 1 bottle, 36 tablets · Aspirin 81 mg 1 bottle, 300 tablets · Acetaminophen ([MEDICATION(S)]) 325 mg 1 bottle, 100 tablets · Acetaminophen 500 mg 1 bottle, 100 tablets · Calcium (dietary supplement) 600 mg 1 bottle, 180 tablets · Thera-M multivitamin/[MEDICATION(S)] supplement 2 bottles, 100 tables each · [MEDICATION(S)] Sulfate (iron supplement) 325 mg 2 bottles, 100 tablets each · Lactobacillus (dietary supplement) 2 bottles, 50 tablets each · Senna ([MEDICATION(S)]) 8.6 mg 4 bottles, 100 tablets each · Stool Softener 100 mg 2 bottles, 100 soft-gels each · [MEDICATION(S)] ([MEDICATION(S)]) 3 mg 1 bottle, 60 tabs · Multi-vitamin 2 bottles, 100 tablets each · Vitamin C 500 mg, 1 bottle, 100 tablets · Vitamin D3 25 mcg 1 bottle, 100 tablets · [MEDICATION(S)] Sulfate [MEDICATION(S)] 220mg / 5 milliliters (ML) 473 ml. · Antacid and Anti-gas 1 bottle 355 mL · Antacid tablets 500 mg 1 bottle 150 tablets · Milk of Magnesia ([MEDICATION(S)]) 1 bottle 473 mL · [MEDICATION(S)] (powder [MEDICATION(S)]) 17.9 ounces b. During an observation on 1/12/22 from 8:45 AM until 8:48 AM on the [NAME] Unit, the medication storage cabinet located in a common area near the resident dining room was observed to be unlocked and unattended by staff with bottles of over-the-counter medications and prescription medication blisters packs. During an interview on 1/12/22 at 8:48 AM, RN #1 stated they had the keys to the medication cabinet and didn't know if the cabinet was to be locked. RN #1 asked Licensed Practical Nurse (LPN) #4 if the cabinet should be locked and LPN #4 stated yes. During an interview on 1/12/22 at 8:50 AM, LPN #4 stated medication cabinets were always to be locked when not attended by the nurse to prevent residents and others from opening and having access to the medications. LPN #4 stated the cabinet should have been locked. Observation on 1/12/22 at 8:50 AM, in the presence of RN #1 and LPN #4 revealed the following over-the-counter medications were located in the [NAME] Unit medication cabinet: · Aspirin 325 milligram (mg) 4 bottles, 100 tablets each · [MEDICATION(S)] Coated Aspirin 325 mg 1 bottle, 100 tablets each · ASA Chewable 81 mg 1 bottle, 36 tablets · Acetaminophen 325 mg 4 bottles, 100 tablets · Acetaminophen 500 mg 4 bottles, 100 tablets · Calcium 600 mg 2 bottles, 180 tablets · Thera-M multivitamin/[MEDICATION(S)] supplement 1 bottle, 100 tables each · [MEDICATION(S)] Sulfate 325 mg 3 bottles, 100 tablets each · Lactobacillus 10 bottles, 50 tablets each · Senna 8.6 mg 6 bottles, 100 tablets each · Stool Softener 100 mg 7 bottles, 100 soft-gels each · Multi-vitamin 3 bottles, 100 tablets each · Vitamin C 500 mg, 2 bottles, 100 tablets · Vitamin D3 25 micrograms (mcg) 1 bottle, 100 tablets · Acetaminophen Suppositories 650 mg, 1 box 12 suppositories · Antacid and Anti-gas 1 bottle 355 mL · Milk of Magnesia 1 bottle 473 mL · [MEDICATION(S)] 17.9 ounces In addition, the following resident specific blister pack medications were on the top shelf in the [NAME] Unit medication cabinet: · Acetaminophen 325 mg, 18 tablets · [MEDICATION(S)] neb (increases airflow to lungs) 2.5 mg - 3mL, 15 vials · [MEDICATION(S)] (antibiotic) 500 mg, 4 tablets · Aspirin chewable 81 mg, 44 tablets · [MEDICATION(S)] Sod Cap (stool softener) 100 mg, 22 tablets · [MEDICATION(S)] HYC (antibiotic) 100 mg, 6 tablets · [MEDICATION(S)] (blood thinner) 2.5 mg, 18 tablets · [MEDICATION(S)] 5 mg, 18 tablets · [MEDICATION(S)] (antacid) 20 mg, 30 tablets · [MEDICATION(S)] (used for dementia) 8 mg, 53 tablets · [MEDICATION(S)] (cough medicine) 200 mg, 162 tablets · [MEDICATION(S)] ([MEDICATION(S)]) 600 mg, 36 tablets · Iprat - albut ([MEDICATION(S)]) (increases airflow to lungs) 0.5-3mg / 3mL, 15 vials · [MEDICATION(S)] (allergy medication) 10 mg, 29 tablets · [MEDICATION(S)] HCL (used for dementia) 5 mg, 30 tablets · [MEDICATION(S)] (antihypertensive) 25 mg, 11 tablets · [MEDICATION(S)] 100 mg, 11 tablets · [MEDICATION(S)] (supplement) 10 MEQ ER, 28 tablets · [MEDICATION(S)]/HCTZ (antihypertensive) 20-25 mg, 30 tablets · [MEDICATION(S)] (high cholesterol) 10 mg, 30 tablets · Sodium [MEDICATION(S)] (antacid) 650 mg, 22 tablets · [MEDICATION(S)] (antidepressant) 25 mg, 8 tablets · Vitamin D3 1000IU (25 mcg), 30 tablets During an interview on 1/12/22 at 9:13 AM, RN #7 Assistant Director of Nursing (ADON) stated the medication cabinets in the common areas should always be locked if unattended by a nurse to prevent residents and others from having access to the medications for resident safety, and it was the responsibility of the nurse who had the keys for the cabinet to ensure the cabinet was locked. During an interview on 1/14/22 at 11:08 AM, the Pharmacy Consultant stated they would have expected all medications cabinets in common areas to be securely locked at all times when unattended by a nurse to prevent access for the safety of the residents. During an interview on 1/14/22 at 11:54 AM, the Director of Nursing (DON) stated they expected all medications cabinets in the common areas to be locked when unattended by a nurse for the safety of the residents. The DON stated it was the responsibility of the nurse to ensure the cabinets were locked. 415.18 (c)(1-4)

Based on observation, interview and record review conducted during a Standard survey completed on 1/14/2022, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin are reported to the administrator as required for one (Resident #74) of one resident reviewed. Specifically, staff did not report facial bruising to their supervisor, Director of Nursing or the Administrator. The finding is: The facility policy and procedure (P&P) titled, Abuse, Neglect, Mistreatment, Misappropriation of Property or Exploitation: Care - Resident Rights dated 11/1/2016 documented; if a staff member has a concern regarding a resident's care, they will notify their immediate supervisor, the Director of Nursing or the Administrator. All accidents/ incidents involving residents will be assessed by the RN (registered nurse); an incident report and follow up investigation will be completed. The facility P & P titled, Accident /Incident Report- Resident dated 11/1/2017 documented; for any injuries of unknown origin, interviews and statement must be part of the investigation to determine the cause and to rule out abuse/neglect. Registered Nurse (RN) assessment is needed with documentation for injuries of unknown origin with full body assessments. 1. Resident #74 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 10/25/21 documented Resident #74 had moderately impaired cognition, makes self understood and usually understands. The Comprehensive Care Plan (CCP) dated 10/19/21 documented Resident #74 is at risk for falls related to history of falls and on 1/3/22 fell on floor with minor injury. Planned interventions included the Falling Leaf Falls Prevention Program. On 1/10/22 at 1:55 PM Resident #74 was observed with a yellowing bruise above their right eye extending to the right temple approximately 2 inches x 2 inches. During an interview at that time of the observation Resident #74 stated they think they got the bruise from a fall and doesn't recall any specifics. Review of the Progress Notes from 10/18/21 through 1/12/22 revealed there was no documented evidence Resident #74 had bruising above their right eye and temple area. Review of the Nursing RN/ Therapy Skin Assessment from 10/18/21 through 1/12/21 for Resident #74 revealed there was no documented evidence of bruising to the resident's right eye and temple area. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Facility Accident/Incident (A/I) Reports provided by the facility dated 10/18/21 through 1/13/22 revealed there was no documented evidence an investigation was initiated related to Resident's #74's bruising above their right (rt) eye. An A/I report dated 1/3/22 revealed at 11:15 PM Resident #74 was found lying on the floor next to the bed on their left side. An RN assessment was completed, and their no visible injuries noted, range of motion (ROM) to all extremities were within normal limits (WNL). Resident offered no complaints of discomfort and denied hitting their head with no visible head injury. In addition, on 1/5/22 Resident #74 complained of left thigh/knee pain with diffuse bruising to the left inner thigh area; doctor was updated, and an x-ray of the left femur and knee were ordered. There was no documented evidence that there was a bruise to Resident #74's right eye and temple. During an interview and observation on 1/13/22 at 10:41 AM, RN #4 stated they were not aware Resident #74 had any bruising on their head or face. During an observation of Resident #74 with RN #4 revealed a yellowing bruise above the resident's rt eye and temple area. During an interview on 1/13/22 at 10:47 AM, Certified Nursing Assistant (CNA) #6 stated they had observed the bruise above Resident #74's right eye on January 4th or January 5th, 2022 and reported it immediately to Licensed Practical Nurse (LPN) #4. CNA #6 stated their responsibility was to report injuries, falls and bruises to the nurse. During interview on 1/13/22 at 10:57 AM RN #4, stated if CNA #6 reported the bruise to a nurse, the nurse should have reported the bruise to supervisor/manager, an RN assessment should have been completed and neuro checks initiated. Additionally, an investigation would have been completed to rule out abuse. During an interview on 1/13/22 at 11:19 AM, LPN #4 stated they recalled observing a bruise above Resident #74's rt. eye with CNA #6 while transferring the resident out of bed either on January 4th or January 5th, 2022. LPN #4 stated they believed the bruise was related to the previous falls but had not looked at the previous A/Is to determine if the bruise was previously noted. LPN #4 stated they didn't document their observation, report it to the Nurse Manger/supervisor or initiate neuro checks and should have. During an interview on 1/14/22 at 11:56 AM, the Director of Nursing (DON) stated they would have expected LPN #4 to have reported Resident #74's bruise to RN #4, and initiated neuro checks. The DON stated an investigation should have been initiated to determine the cause of the bruise and to rule out abuse. During an interview on 1/14/22 at 11:57 AM, the Administrator stated they would have expected the nurse to report the bruise to their Nurse Manager or Nursing Supervisor, an RN assessment completed, and an investigation initiated immediately to rule out abuse. 415.4 (b)(2)

Based on observation and interview during the Standard survey completed on 1/14/22, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Specifically, shower plumbing devices and hoses did not have vacuum breakers installed to prevent backflow in eight ([NAME]/Pines House tub/shower room, Wells/[NAME] tub/shower room, Harmony House tub/shower room, [NAME] House tub/shower room, [NAME] House tub/shower room, Wesley House tub/shower room, Horizons House low side tub/shower room, Horizons House high side tub/shower room) of eleven tub/shower rooms located in two (East Village Building and West Village Building) of two resident use buildings. The findings are: 1. a) Observation in the East Village Building on 1/10/22 at 8:50 AM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the [NAME]/Pines House tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. During an interview at the time of the observation, the Director of Plant Operations stated there is no vacuum breaker on this device because they usually use shorter hoses that don't reach the shower floor. b) Observation in the West Village on 1/10/22 at 1:10 PM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the Wells/[NAME] House tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. During an interview at the time of the observation, the Director of Plant Operations stated the hose that is currently connected is not the hose that came with the fixture. c) Observation in the West Village on 1/10/22 at 2:10 PM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the Harmony House tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. d) Observation in the West Village on 1/10/22 at 2:33 PM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the [NAME] House tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. e) Observation in the West Village on 1/10/22 at 2:52 PM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the [NAME] House tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. f) Observation in the West Village on 1/10/22 at 3:30 PM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the Wesley House tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. g) Observation in the West Village on 1/11/22 at 9:35 AM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the Horizons House low side tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. h) Observation in the West Village on 1/11/22 at 10:00 AM revealed the hand-spray wand in the shower stall was not equipped with a vacuum breaker in the Horizons House high side tub/shower room. Additional observation at this time revealed the length of the hose allowed the hand-spray wand to be submerged if the shower's floor drain did not drain properly. 415.29(d)(f)(4)

Based on observation, interview, and record review conducted during the COVID-19 Infection Control Focus Survey (Case #NY 304) completed on 5/26/20 it was determined that the facility did not maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility readmitted a resident from the hospital diagnosed with [REDACTED]. This involves Resident #1 and #2. The findings are: The Executive Order #202.30 dated May 10, 2020 documented the following: Any article 28 general hospital shall not discharge a patient to a nursing home, unless the nursing home operator or administrator has first certified that it is able to properly care for the patient. Provided further, that any article 28 general hospital shall not discharge any patient to a nursing home, without first performing a diagnostic test for COVID-19 and obtaining a negative result. 1. Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (a resident assessment tool), dated 4/14/20, documented the resident was severely cognitively impaired, was understood and usually understands. Review of the Hospital Discharge Summary dated 5/19/20 revealed Resident #2 tested positive for COVID-19 on 5/4/20 at the nursing home. The resident had an overall decline and was admitted to the hospital on [DATE]. The resident was tested on [DATE] and continued to be positive for COVID-19. Resident #2 was discharged back to the facility on [DATE] without a negative result on a COVID-19 diagnostic test. During an interview on 5/21/2020 at 4:10 PM, the Administrator stated Resident #2 tested positive for COVID-19 at the facility, went to the hospital, returned to the facility still positive for COVID-19 on 5/19/20. The interview further revealed the Administrator was going to look up the Executive Order regarding readmission of residents and review it. 2. The P&P titled Transmission Based Precautions dated 3/4/20 documented under Droplet Precautions staff will wear a mask, face shield, gloves and gown when working with a resident or in a resident's room. During an observation on 5/21/2020 at 9:45 AM Housekeeper (#1) was observed wearing an N95 mask and no other PPE going in and out of Resident #1's room cleaning. Housekeeper #1 pulled down her mask under her chin in the hallway near the cleaning cart, wiped her nose with a tissue and placed the N95 mask back up to the nose area. The housekeeper did not complete hand hygiene after wiping her nose, picked up the mop from the cart and went back into Resident #1's room to mop the floor. During an interview on 05/21/2020 at 10:09 AM, Housekeeper #1 stated she wears a N95 mask when cleaning resident rooms. She stated that she was educated on donning and doffing PPE and the different zones (green, yellow, red) within the facility. Furthermore, the housekeeper stated she was told there were no residents diagnosed with [REDACTED]. During an interview on 05/21/2020 at 10:11 AM, the Assistant Director of Nurses (ADON) stated when staff are in the halls on yellow zone, they should be wearing a N95 mask, if going into a resident room on the yellow zone, the staff need to be in full PPE. 415.19 (b)(1)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY 476) completed on 2/6/20, the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADL's) receives the necessary services to maintain personal hygiene. Specifically, two (Residents #1 and 3) of three residents reviewed for ADL's did not receive appropriate nail care. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 1/3/20 documented the resident had severe cognitive impairment. Review of a Visual/Bedside Kardex Report (guide used by staff to provide care) with a print date of 2/6/20 revealed the resident required total assist for grooming, was to receive showers every Sunday and Thursday on the 11:00 PM to 7:00 AM shift, and staff were to re-approach resident if they were resistive to care. Review of Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED] Review of the Progress Notes dated 1/1/20 through 1/27/20 revealed the following: 1/2/20 - sacral treatment completed with fresh bleeding noted on dressing, blood and skin and under the resident's nails. 1/5/20 - tugging at Foley (tube inserted into bladder to drain urine) and sticking fingers in their genital area 1/19/20 - sticking fingers in oatmeal. 1/27/20 - resident trying to scratch sacral area (pressure sore) and putting hands in their genital area. Additional review of the Progress Notes from 1/1/20 through 2/5/20 revealed only two documented attempts to provide nail care on 1/22 and 1/29. During an observation on 2/6/20 at 8:20 AM revealed the resident's fingernails on both hands were long, jagged and dirty with packed with brown debris. During an interview on 2/6/20 at 8:25 AM, the Registered Nurse (RN) Unit Manager #1 stated the resident's nails were long, dirty and should be cleaned. During an interview on 2/6/20 at 10:58 AM, Licensed Practical Nurse (LPN) #1 at stated she had tried to cut residents nails recently. The LPN could not remember when, but the resident refused by scratching and punching. The LPN further stated the resident does play in their feces and it gets under their fingernails. During an interview on 2/6/20 at 1:00 PM, LPN #1 stated there should have been an order to trim the resident's nails, but it must not have carried over when the resident returned from the hospital. 2. Resident #3 has [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had severe cognitive impairment. Review of a Visual/Bedside Kardex Report with a print date of 2/6/20 revealed the resident required assist supervision for grooming. Review of Progress Notes dated 12/4/19 revealed the granddaughter (HCP, health care proxy) was visiting and requested staff to clean under underneath the resident's nails. Review of Progress Notes from 12/5/19 through 2/5/20 revealed there was no documentation the resident was refusing nail care. The notes did document concerns from the healthcare agent the resident had dirty fingernails. During observation on 2/6/20 at 8:26 AM, the resident's fingernails were uneven. Some nails were long, some short; some painted; some not. The resident's fingernails had visible brown debris underneath them. During interview on 2/6/20 at 8:35 AM, the RN Unit Manager #1 stated the resident's fingernails were long and dirty and they should be cut and cleaned. During interview on 2/6/20 at 1:30 PM, Certified Nurse Aide (CNA) #1 stated he took care of the resident in the weeks prior, they clean nails on shower days but no there is nowhere to document the care provided. During interview on 2/6/20 at 1:35 PM, CNA #2 stated she was the resident's aide this week. She gave the resident a shower the day before and meant to clean her nails. The resident wanted to go to bingo, so she figured she would clean them after bingo but forgot about it. The policy and procedure titled Care and treatment of [REDACTED]. Certified Nurse's Aide (CNA) working at the facility may cut fingernails. During an interview on 2/6/20 at 2:50 PM, with the Director of Nursing (DON) stated the policy was the same for diabetic nail care and nail care. 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 5/9/19, it was determined that the facility did not maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, ten (Arms,(NAME) Garvin, Eschelman, Harmony, Holzman, Horizon, Hospice,(NAME) Wesley) of 15 resident household washing machines reviewed for safe operating condition had black debris on the rubber door gaskets and stale mildew odors in the washers. The findings are: 1. During an interview on 5/6/19 at 11:30 AM, a family member of Resident A revealed that the frontloading washing machine on the(NAME)Household had a smell to it and had a black ring around the inside of the door. Observations of the facility's frontloading washing machines between 5/7/19 and 5/9/19 revealed the following: - 5/7/19 at 8:11 AM -(NAME)Household - the washing machine had the door closed. The Surveyor opened the door and observed black debris all around the inside rubber gasket. The washer had a slight mildew odor on the inside. A note taped to the front of the door read to leave the door open between cycles and clean gasket with Affresh wipes every Tuesday. Interview with a Registered Nurse (RN #5) at the time of the observation revealed that bibs/clothing protectors, bedspreads, or residents' clothing at the request of family, are washed in the washer. - 5/8/19 at 3:31 PM - Horizon Household - the washing machine in the soiled utility room had a large amount of black debris along the bottom of the gasket. The washer and the soiled utility room had a musty, mildew odor. The washer contained an unidentified green clothing item which was dry to the touch. - 5/9/19 at 6:34 AM - Harmony Household - the door of the washing machine, located next to the servery area, was closed. A note affixed to the door stated it was to be kept open between cycles and to be wiped with a cleaning wipe every Tuesday. There was a slight mildew odor on the inside of the machine. Interview with a Licensed Practical Nurse (LPN #1) revealed that clothing protectors, slings for the sit to stand lift, and residents' soiled personal clothing are washed in this washer. The LPN could not confirm who was responsible for the care and upkeep of the washer. - 5/9/19 at 6:39 AM - Eshelman Household - the washing machine door was closed. A note affixed to the door stated that the door should be kept open and wiped with a wipe every Tuesday. The washer had a very slight mildew odor when the door was open. The washer contained slings and clothing protectors. Interview with a Certified Nurse Aide (CNA #2) revealed that staff put clothing protectors, slings, and residents' clothing in this machine. She was not sure who was responsible for the washing machine. - 5/9/19 at 6:44 AM - Holzman Household - the washing machine door was closed. A note affixed to the door stated it is to be kept open and wiped every Tuesday. The Surveyor opened the door and observed black debris all around the rubber gasket and the washer had a mildew odor. Interview with CNA #3 revealed that they wash clothing protectors, but she was not sure if they washed anything else in it. She was not sure who was responsible for the cleaning of the washer. - 5/9/19 at 6:49 AM - Arms Household - the washing machine door was open with a note affixed to it for the door to be kept open and wiped with a wipe every Tuesday. Inside the washing machine there was a strong mildew odor and the gasket had a heavy coating of black debris all around it. - 5/9/19 at 6:54 AM -(NAME)Household - the washing machine was located in a separate closet type room. The door of the machine was closed with a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The washer had a mildew odor. Interview with CNA #4 revealed that residents' clothes are washed in this machine if they or their families do not have a washing machine. She cleans it when she is finished with it. - 5/9/19 at 7:37 AM -(NAME)Household - the washing machine was located next to the server. The washer door was closed with a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The Surveyor opened the door and there was an area of black debris on the bottom of the gasket, three inches long and one inch wide, with a mildew odor. Interview with Homemaker #4 at revealed that she only puts clothing protectors in the washer. She cleans it after she is done with the washer. - 5/9/19 at 7:46 AM - Hospice Household - the washing machine door was open. There was a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The Surveyor opened the door and there was a mildew odor. Interview with CNA #1 revealed that she washes clothing protectors and slings in the machine. She was not sure who is in charge of maintenance of the washers. - 5/9/19 at 7:58 AM - Garvin Household - the washing machine door was open. There was a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The gasket around the opening had black debris and a strong mildew odor. Interview with Homemaker #1 revealed that clothing protectors, shower robes, and residents' personal clothing gets washed in the machine if they become soiled. - 5/9/19 at 8:16 AM -(NAME)Household - the washing machine door was open. The gasket around the opening had black debris all around it and there was a strong mildew odor. There was a small puddle of water at the bottom of the gasket. Next to the washer, there were folded clothes and clothing protectors that appeared to be freshly washed and dried. Interview on 5/9/19 at 9:28 AM with the RN Infection Preventionist revealed that she expects that staff not use a washing machine if there is black debris on the gasket and is smelly. She said that staff should clean it or report it to housekeeping. Interview on 5/9/19 at 9:46 AM with the Facilities Director revealed that he was not aware of the issue. He stated that there needs to be staff education about the washers even though there are notes about the front loader door needing to be left open and the washer needs to be wiped down. He will have maintenance staff replace what gaskets they can now, and they will have new gaskets for the other washers in a few days. He will have residents' personal clothing go to laundry and the clothing protectors should be washed in the household washers. Review of a facility policy and procedure (P&P) entitled Household Washing Machine Cleaning Procedures dated (MONTH) (YEAR) revealed that staff are to maintain overall cleanliness and sanitation of washing machines on the households and must do the following: 1. After completed wash, remove items, and then use the machine cleaning wipes. 2. Wipe thoroughly the machine door gasket. 3. Leave washing machine door open after each use and when not in use. 415.29(b)

Based on observation, interviews, and record review conducted during the Standard survey, completed on 5/9/19, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #218) of two residents reviewed for feeding tubes. Specifically, the facility did not provide tube feed formula as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: 1. Resident #218 was admitted [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 4/16/19 documented the resident was cognitively intact. Review of an Order Summary Report (physician's orders [REDACTED]. During an observation of the resident on 5/3/19 at 11:45 AM revealed the resident's tube feed formula, [MEDICATION NAME] 1.5 was running via PEG at 50 cc per hour. During an observation on 5/7/19 at 8:05 AM revealed the resident's tube feed formula, Impact 1.5 was running via PEG at 50 cc an hour. During an interview on 5/7/19 at 12:00 PM the resident stated the feed was on continuously except during therapy and care. The Impact 1.5 formula was still running at 50 cc/hr. at that time. Review of the Order Summary Reports and Interdisciplinary Team Notes (IDT) dated 5/6/19 through 5/7/19 revealed a lack of documented evidence for a change in formula. Review of the Medication Administration Record [REDACTED]. During an observation on 5/7/19 3:10 PM in the presence of the Registered Nurse (RN) Unit Manager #4 revealed the resident still had the Impact 1.5 formula running via a pump through the PEG tube. Interview with the RN #4 at the time of the observation stated she was unaware of any formula changes for the resident. During an interview on 5/8/19 at 7:35 AM, RN #4 stated the wrong formula order was placed in the resident's closet. The nurse didn't look at the tube feeding when she hung it. The resident now has the correct formula. Additionally, a medication error report form was completed for the night nurse for hanging the wrong formula and the day nurse who didn't identify it was the wrong formula. During an interview on 5/8/19 at 8:15 AM, RN #4 stated generally the Unit Clerk signs the invoice for the formula and the delivery person puts the formula in the resident's closet in their room. It was the nurse's responsibility to check the packaging of the product to make sure it's the right formula before hooking it up (providing the formula to the resident). During an interview on 5/9/19 at 6:24 AM, the night shift Licensed Practical Nurse (LPN #5) stated she hung the bag of Impact 1.5. She stated there was a big box of the Impact 1.5 formula instead of the [MEDICATION NAME] formula in the resident's closet and assumed there was a new order for that formula. The LPN stated she should have checked the order or verified the order with the physician if she was not sure. During a telephone interview on 5/9/19 at 1:00 PM, the day shift LPN #6 stated she did not hang the bag of Impact 1.5 formula, so she didn't check it. 415.12 (g)(2)

Based on interview and record review conducted during the Standard survey completed on 5/9/19, the facility did not ensure that a written summary of the baseline care plan, that included initial goals, a list of current medications, dietary instructions, and services/treatments to be administered by facility and personnel acting on the behalf of the facility, was provided to the resident or the resident's representative. Specifically, 17 (Residents #16, 21, 44, 58, 99, 118, 127, 158, 162, 180, 184, 218, 219, 233, 282, 431, 481) of 17 admitted residents reviewed for Baseline Care Plans had no documented evidence that Baseline Care Plans were completed or that a written summary of the baseline care plan was provided to the resident and/or the resident's representative by completion of the comprehensive care plan. The findings include but are not limited to: A facility policy and procedure entitled Baseline (New Admission) Care Plan dated 12/1/17 documented a baseline care plan will be developed within the first 48 hours of admission for each resident to promote continuity of care and communication among staff, enhance resident safety, and to ensure the resident /responsible party are informed of the initial plan of care. 1. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/22/19 documented the resident was severely cognitively impaired, understood and usually understands. Review of interdisciplinary team Progress Notes dated 2/12/19 through 2/19/19 revealed no documented evidence that a baseline care plan was provided to the resident or the resident's representative. During an interview on 5/8/19 at 1:36 PM, the Director of Social Work stated the Kardex is done immediately but is not all inclusive. The baseline care plans (Kardex) are on the back of the resident's door. The residents and families have access for review, if desired. It is available to them. We offer copies to them if they request, we don't just give them a copy. At the initial care plan meeting, about 21 days after admission, the care plan is reviewed with them. Review of the resident's Kardex (care guide used by staff to provide care) dated 2/12/19 revealed that it did not contain information as required for the Baseline Care Plan. The Kardex did not include initial goals, physician's orders [REDACTED]. During an interview on 5/8/19 at 1:57 PM, Registered Nurse (RN) MDS Nurse stated the RN Unit Manager (UM) or Nursing Supervisor completes the admission care plan, a template that consists of Activities of Daily Living (ADL), mobility, toileting, risk factors, diet, and code status. A copy is not provided to the family and/or resident. The Director of Nursing (DON) spoke to me about it a couple months ago and we were looking at templates from other facilities. We have not determined a template yet or process of notification to resident and/or family. During an interview on 5/9/19 at 8:09 AM, the DON stated the Kardex on the door is the baseline care plan. The RNs do the admission care plan of ADLs, safety, the essentials. Goals and physician orders [REDACTED]. It is reviewed with the family. Medications are not addressed. If they ask we go over it. A copy is not provided unless they ask because it's on the back of the door. She stated they are in the process of looking at different templates, but the process hasn't been developed yet and there is no formal process for documentation. The Comprehensive Care Plan is completed within 21 days, and they have a care plan meeting. Everything is reviewed, but we don't give them a copy unless they ask for it. During an interview on 5/9/19 at 9:45 AM, the Registered Nurse (RN # 5) Unit Manager stated when a resident is admitted to the facility, a plan of care is initiated after reviewing the resident's paperwork and talking with the resident and their family regarding preferences and main points of care. RN #5 stated I do not give them a copy of the care plan, I was not aware they should be provided with a copy. During an interview on 5/9/19 at 11:12 AM, the Administrator stated I have nothing for baseline care plans yet, we haven't finished formalizing the process. I'll take responsibility for that. They haven't been doing a full baseline care plan. The Kardex is developed immediately with the initial information. We have not been giving them to the family or the resident. We knew that we needed to get something into place. We have reviewed templates from other facilities, we just haven't finished the process. 2. Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had severe cognitive impairment. Review of the resident's medical record, including IDT (interdisciplinary team) progress notes dated 8/14/18 to 8/21/18, revealed no documented evidence a written summary of the baseline care plan was provided to the resident or resident's responsible party. During an interview on 5/9/19 at 9:22 AM, the Registered Nurse (RN #6) Neighborhood Manager stated when someone initially comes in they do complete an initial care plan and a Kardex, but they haven't been going over it with the family or giving them a copy. Review of the Kardex (guide used by staff to direct care) dated 8/15/18 revealed that it did not contain information as required for the baseline care plan. The Kardex did not include diagnoses, initial goals, physician's orders [REDACTED]. 3. Resident #431 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed that the resident was cognitively intact, understood, and understands. Chronological review of the resident's medical record revealed [REDACTED]. The resident refused to be interviewed on 5/9/19. Interview on 5/9/19 at 11:18 AM with Licensed Practical Nurse (LPN #3) revealed they do an initial care plan when the resident is admitted . They go over the Kardex (a care plan for the certified nurse aides) with the resident and the family and the Kardex is posted on the back of the resident's door. If the family or the resident wanted a copy of the Kardex, they would give them one. Review of the resident's Kardex dated 4/17/19 revealed that it did not contain information as required for the Baseline Care Plan. The Kardex did not include diagnoses, initial goals, physician's orders [REDACTED]. 415.11(c)(1)

Based on interview and record review conducted during the Standard survey completed on 11/15/17, the facility did not inform the resident's legal representative or interested family member or immediately consult with the resident's physician when there is a significant change in the resident's physical, mental or psychological status and a need to alter treatment significantly. Two (Resident #90, 147) of four residents reviewed for physician notification had issues involving the lack of physician notification of abnormal (low and high) blood glucose levels according to physician orders. The findings are: Review of a facility policy and procedure (P&P) entitled Physician/Family Notification dated 8/4/17 revealed The facility will keep the physicians and the resident's family/responsible party appraised of the condition of the resident under their care. Significant and unexpected changes in the condition-physical status, laboratory test result, psycho social or functional status deviations will be reported to the physician. 1. Resident #147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/7/17 revealed the resident has severe cognitive impairment. Review of an Order Summary Report, signed 11/3/17, revealed a physician order [REDACTED]. Additional review of the Order Summary Report revealed the following medication orders [REDACTED] - Humalog (fast acting insulin) inject as per sliding scale (dose of insulin therapy based on blood glucose results) before meals. - [MEDICATION NAME] (diabetic medication) 50 milligrams (mg) by mouth daily - [MEDICATION NAME] (long acting insulin) 18 units subcutaneous (injection beneath the skin) daily Review of a Consultant Pharmacist/ Physician/Prescriber Communication Form dated 10/3/17 revealed the pharmacist's recommendation to Consider discontinuing [MEDICATION NAME] as it did not avoid the purpose for sliding scale. By focusing first on the largest meal of the day, please adjust his Humalog so that he can be maintained on a scheduled dose. The physician's response was I am trying to get rid of the sliding scale, would try to get rid of sliding scale as part of the goal. Review of a Physician's 60-Day Note dated 11/3/17 revealed the physician documented stable on [MEDICATION NAME] and [MEDICATION NAME] in the assessment section for diabetes mellitus. Review of the Medication Administration Report (MARs) dated October 1, 2017 to November 14, 2017 revealed the resident had blood glucose levels outside of the ordered range on the following dates: - 10/2/17 at 4:30 PM - 453 - 10/4/17 at 4:30 PM - 422 - 10/27/17 at 4:30 PM - 531 - 11/10/17 at 4:30 PM - 471 Review of the electronic Progress Notes dated 10/1/17 through 11/14/17 revealed no documented evidence that the physician was notified of the resident's blood glucose levels greater than 400 on the dates listed above. During an interview on 11/14/17 at 8:49 AM, a Licensed Practical Nurse (LPN #1) stated that if a resident's blood glucose level is over 400, the nurse would call the doctor. LPN #1 stated that most diabetic residents on the nursing unit are on a sliding scale, so she would administer the insulin dose ordered and the physician may order additional units of insulin. During an interview on 11/14/17 at 9:10 AM, the Registered Nurse (RN #1) Unit Manager (UM) stated that nursing staff should immediately inform the physician of blood glucose levels over 400 and document the notification in the progress notes. When reviewing the resident's progress notes, RN #1 stated I do not see any notes, I do not know why there are not any. 2. Resident #90 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment. Review of an Order Listing Report dated 9/1/17 through 11/30/17 revealed physician orders [REDACTED]. Additional review revealed the following medication orders [REDACTED] - Humalog per sliding scale: 0-150=0 units, 151-200=3 units, 201-250=6 units, 251-300=9 units, 301-350=12 units, 351-400=15 units, 401-500=18 units subcutaneously before meals for DM. Call physician if FS is < 70 or >100. Review of MARs dated 9/7/17 through 10/11/17 revealed the resident had the following blood glucose results: - 9/7/17 at 4:30 PM - 407 - 9/13/17 at 4:30 PM - 472 - 9/24/17 at 4:30 PM - 404 - 10/6/17 at 4:30 PM - 66 - 10/11/17 at 4:30 PM - 433 Review of the electronic progress notes dated 9/7/17 through 10/11/17 revealed no documented evidence that the physician was notified of the resident's blood glucose levels less than 70 or greater than 400 on the dates listed above. Interview with a Licensed Practical Nurse (LPN #2) on 11/15/17 at 8:45 AM revealed that if a resident's blood glucose level is below 70, she would give orange juice per policy and notify the physician. If the blood glucose is over 400, she would call the physician and document either event in the Progress Notes. During an interview on 11/15/17 at 11:30 AM, the Registered Nurse (RN #2) Unit Manager stated we were noticing the resident's blood sugars would be high after returning from outings with her daughter. Staff should be documenting when blood sugars are <70 or >400 in the Progress notes after calling the physician. Interview with the Assistant Director of Nursing (ADON- RN #3) on 11/15/17 at 12:40 PM revealed We see what the problem is and are going to in-service the nurses immediately. 415.3(e)(2)(ii)(b,c)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/15/17, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #164) of five residents reviewed for accidents was left unattended by staff in the bathroom and was assisted to a standing position by staff holding the resident under her arm. In addition, the facility's fall prevention program was not fully implemented to identify that the resident was at high risk for falls. The finding is: 1. Resident #164 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/5/17 revealed the resident has severe cognitive impairment, usually understands, and is usually understood. Review of the current comprehensive care plan (CCP) last reviewed 10/16/17 revealed the resident was identified at risk for falls related to depression, anxiety, use of medication, and decreased mobility and has a history of falls. Planned interventions include but are not limited to the following: - Falling Leaves Program (program to identify residents at high risk for falls) - Do not leave unattended when in the bathroom - PT (physical therapy)/OT (occupational therapy) to evaluate and treat - Supervised area when out of bed - Review information on past falls and attempt to determine cause of falls The CCP for ADL (activities of daily living) performance included planned interventions to provide supervision for transfers and supervision for ambulation using a rolling walker. The CCP also identified that the resident has potential for elopement with planned interventions for every 30-minute safety checks. Review of the Bedside Kardex Report, used by staff to provide care, dated 11/14/17 revealed the resident requires supervision for transfers; extensive assistance of one person for toileting, hygiene, and clothing management; and is not to be left unattended when in the bathroom. Additional review of the Bedside Kardex Report revealed the resident requires a rolling walker for ambulation, every 30 minutes safety checks, and is on the Falling Leaves fall prevention program. Review of a Record of Incident report dated 10/26/17 at 1:39 AM revealed the resident had an unwitnessed fall and was found laying on the floor on her left side, walker laying next to her. The A&I Report documented there was light reddened area on the left side of her back. Follow-up interventions to prevent recurrence included to continue every 30-minute safety checks and install a night light in the resident's room. Review of a Record of Incident report dated 11/4/17 at 4:51 PM revealed the resident had an unwitnessed fall and was found sitting on her buttocks on the floor with her legs extended straight out in front of her. There was no apparent injury. Follow-up intervention to prevent recurrence was to obtain a PT evaluation for ambulation. The Root Cause Analysis Post A&I (Accident and Incident) dated 11/4/17 documented that the resident has no safety awareness and attempted to ambulate without assist Review of a PT evaluation dated 11/9/17 revealed the resident continues to require supervision for transfers and ambulation with a rolling walker with verbal cues for safety. Observation on 11/14/17 at 7/27 AM revealed a certified nurse aide (CNA #1) left the resident in the bathroom, went into the living room area down the hall and returned to the resident's room at 7:29 AM. Continued observation at 7:31 AM revealed the CNA positioned a gait belt (an assistive device used to transfer a resident with mobility issues from one position to another) around the resident's waist, placed her left arm under the resident's left armpit and instructed the resident to stand up on the count of three. On the count of three, the CNA used her left arm to lift up the resident from the toilet to a standing position and did not utilize the gait belt. The resident was unable to stand up unassisted and the CNA pulled her up to a standing position. During an interview on 11/14/17 at 7:40 AM, CNA #1 stated that she typically checks the Bedside Kardex before starting care, but did not check it this time and was unaware that the resident was not to be left unattended in the bathroom. The CNA also stated this was not her regular floor and she thought the resident had a wheelchair, so went to find out where her wheelchair was. The CNA stated that gait belts are used for balance and stability during a transfer and are required for residents who require a limited or extensive assist and stated If I read the Kardex I would have known that she didn't even need a gait belt. You can use it if you want too. I do not remember lifting her with my arm. I should have put the call light on and asked for someone to see where her wheelchair was, instead of leaving the room. During an interview on 11/14/17 at 10:38 AM, CNA #4 stated that gait belts give a sense of security, stability and control during a transfer. The CNA stated that All CNA's should use them and he always puts his hand under the belt for better control. He stated that gait belts are used to prevent tugging on the arms and causing injury to the resident. The CNA stated he always checks the Kardex prior to performing care. During an interview on 11/14/17 at 7:48 AM, the Registered Nurse (RN #4) Neighborhood Manager stated that gait belts are used for residents who require limited or an extensive assistance with transfers. If staff chooses to use a gait belt for someone requiring supervision, she would expect them to have their hand on the belt during the transfer for support to prevent injury. The RN Manager stated that she expects the CNAs to check the Kardex before giving care to the resident, especially because she is at a risk for falls and is on the Falling Leaves program. During further interview on 11/14/17 at 11:38 AM, the RN Neighborhood Manager stated that the residents on the Falling Leaves program are residents who are at high risk for falls and are identified with a magnetic leaf on their door, wheelchair or walker. Qualifying residents are those who have had two or more falls in 30 days with or without injury and they can remain on the program for six months or until the IDT (Interdisciplinary Team) feels it is no longer necessary. Observation on 11/14/17 at 11:50 AM revealed the resident was sitting in her straight back chair in the dining room and there was with no picture of a leaf on her walker. Observation of the resident's room with CNA #3 on 11/14/17 at approximately 11:51 AM revealed there was no magnetic leaf on the door. During an interview on 11/14/17 at 11:51 AM, CNA #3 stated that typically residents who are at high risk for falls are on the Falling Leaves program and are identified with a picture of a leaf on their wheelchair, walker or door. CNA #3 verified that Resident #164 did not have a leaf displayed on her door or her walker. During an interview on 11/14/17 at 12:03 PM, CNA #1 stated this morning when she provided care to Resident #164, she was unaware that the resident was on the Falling Leaves program because there was no leaf on the door. During interview on 11/15/17 at 10:32 AM, the Assistant Director of Physical Therapy stated that any residents who require limited or extensive assistance for transfers must use a gait belt. If the resident is supervision and there's a gait belt because the staff feel that the resident might need it, then the staff should use it properly, lifting a resident underneath their armpit is not recommended. During an interview on 11/15/17 at 9:18 AM, the Director of Nursing, DON stated she was not too familiar with the Falling Leaves program as she has only been at the facility for one month. The expectations are if someone is on the program that they are identified appropriately by placing a leaf on the door or wheel chair or walker. The DON stated that the CNA should have put the call light on instead of leaving the resident alone in the bathroom and transferring the resident under the armpit is unacceptable. Review of a facility policy and procedures (P&P's) revealed the following: - Gait Belts dated 11/13/15 - Gait belts will be used by appropriate direct care staff to assist in transferring and ambulating residents to help ensure safety of residents and staff members by providing a firm grasping surface for the care giver and a sense of security. The gait belt is firmly grasped by the staff member and used to assist resident to transfer or ambulate according to the care plan. - Transfer Techniques - Basics dated 5/11/01 - The section entitled Principles to Remember documented The assistant never grasps the resident by their arms; assist with gait belt. - Falling Leaves Program dated 12/8/16 - The program is put into place to heighten staff awareness for residents who are at high risk for falls. The program is initiated when 1) a resident fall with serious injury or has two falls within 30 days. 2) Anytime a resident condition warrants Falling Leaf Program without a fall occurring. 3) Falling Leaves program will be identified by: a) care plan b) Kardex c) Falling leaves sticker on the door and walkers d) weekly falling leaf report. 415.12(h)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 109) completed on 7/11/17, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #1) of three residents reviewed for quality of care related to a significant change in condition had an issue involving an incomplete Registered Nurse (RN) assessment of the resident who was hypoglycemic (low blood glucose level). The finding is: 1. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/24/17 revealed the resident has moderate cognitive impairment. Review of a physician's orders [REDACTED]. Review of physician's orders [REDACTED]. The order directed to start the tube feeding at 4:00 PM, run continuously and turn off at 8:00 AM. Review of the June 2017 Medication Administration Record [REDACTED]. The Regular insulin dosage was based on finger stick (FS - sample of blood to determine glucose level) levels as follows: FS 0-150 = 0 units FS 151-200 = 3 units FS 201-250 = 6 units FS 251-300 = 9 units FS 301-350 = 12 units FS 351-400 = 15 units FS 401-500 = 18 units Call MD (medical doctor) if less than 70 or greater than 500. Additional review of the June 2017 MAR indicated [REDACTED]. At 11:30 AM, the FS was 405 and 18 units of Regular insulin was given. Review of a Nursing Progress Notes dated 6/23/17 revealed at 1:00 PM the physician was in and was updated regarding the resident's elevated FS and status. At 2:00 PM, a new order was received to increase the [MEDICATION NAME] to 25 units daily. Further review of the June 2017 MAR indicated [REDACTED] - on 6/23/17 at 5:30 PM, the FS was 57 and 0 units of insulin was given - on 6/23/17 at 8:30 AM, the FS was 57 and 0 units was given Review of a Nursing Progress Note, written by a Licensed Practical Nurse (LPN #1), dated 6/23/17 at 10:53 PM revealed the resident's FS was 43 at the start of the shift and the [DEVICE] feeding was started. The LPN documented a call was placed to the MD and the Nurse Practitioner (NP) responded with an order to hold the sliding scale insulin coverage for the rest of the shift. The RN (registered nurse) Manager was consulted and advised that orange juice and sugar be given via the [DEVICE] to avoid any worsening of his state. A repeat FS of 57 was obtained at 5:00 PM. At 10:30 PM. the resident was alert and able to make needs known. Ambulated with assist to the bathroom, then back to bed, resting comfortably. Additional review of the medical record, including Nursing Progress Notes dated 6/23/17 revealed no documented evidence that an RN assessed the resident's condition on 6/23/17, when the FS' were 43 and 57. During a telephone interview on 6/30/17 at approximately 12:30 PM, the RN (#1) Manager/ Supervisor stated that on 6/23/17 at approximately 5:00 PM, LPN #1 informed her that Resident #1's FS was 57, and LPN #1 had contacted the NP who ordered no further insulin coverage the remainder of the shift. RN #1 stated she instructed LPN #1 to give orange juice and sugar via the [DEVICE] and re-check the FS in 20 minutes. RN #1 stated I looked in on the resident and he was a little sweaty and could answer yes or no. I didn't take his vital signs or pulse ox (oximetery- oxygen saturation level in the blood) or do any other assessments. RN #1 stated that LPN #1 informed her that Resident #1's FS went up, however she did not check on him later in the shift. Review of a facility policy and procedure (P&P) entitled Blood Glucose Monitoring dated 9/3/14 revealed that a blood glucose level may be obtained under the following circumstances: for intermittent monitoring of residents with diabetes mellitus at the direction of the physician or nurse's discretion. The P&P documented that the nurse determines if the resident is exhibiting the following signs and symptoms; [DIAGNOSES REDACTED] - tremors, diaphoresis (sweating), restlessness, confusion, increased pulse, increased blood pressure, [MEDICAL CONDITION](rapid heart rate), anxiety, emotional reactions, nausea, dizziness, headache, convulsions, coma. Review of a facility P&P entitled Resident Change in Condition dated 7/6/12 revealed the RN/LPN will alert the RN Nurse Manager/ RN Supervisor of any significant change in a resident's condition for further assessment. During an interview on 7/11/17 at approximately 10:00 AM, the Director of Nursing (DON) stated that her expectation of RN #1 was to perform a head to toe, side to side assessment. Vital signs (blood pressure, temperature, pulse, respiratory rate), neurological, cognition, respiratory, range of motion; all the systems. During the interview the DON stated no additional information was available. 415.12

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 109) completed on 7/11/17, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #1) of three residents' medical records reviewed for accurate documentation of a significant change in condition had an issue involving incomplete or lack of documentation regarding the resident who was hypoglycemic (low blood glucose level). The finding is: 1. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/24/17 revealed the resident had moderate cognitive impairment. Review of a physician's orders [REDACTED]. Review of physician's orders [REDACTED]. The order directed to start the tube feeding at 4:00 PM, run continuously and turn off at 8:00 AM. Review of the June 2017 Medication Administration Record [REDACTED]. The Regular insulin dosage was based on finger stick (FS - sample of blood to determine glucose level) levels as follows: FS 0-150 = 0 units FS 151-200 = 3 units FS 201-250 = 6 units FS 251-300 = 9 units FS 301-350 = 12 units FS 351-400 = 15 units FS 401-500 = 18 units Call MD (medical doctor) if less than 70 or greater than 500. Additional review of the June 2017 MAR indicated [REDACTED]. At 11:30 AM, the FS was 405 and 18 units of Regular insulin was given. Review of a Nursing Progress Note dated 6/23/17 revealed at 1:00 PM the physician was in and was updated regarding the resident's elevated FS and status. At 2:00 PM, a new order was received to increase the [MEDICATION NAME] to 25 units daily. Further review of the June 2017 MAR indicated [REDACTED] - on 6/23/17 at 5:30 PM, the FS was 57 and 0 units of insulin was given - on 6/23/17 at 8:30 AM, the FS was 57 and 0 units was given Review of a Nursing Progress Note dated 6/23/17 written by a Licensed Practical Nurse (LPN) #1 included FS 43 at start of shift. [DEVICE] started. Call to MD, Nurse Practitioner (NP) responded with order to hold sliding scale for the rest of the shift. RN #1 Manager consulted and advised orange juice and sugar via [DEVICE] to avoid worsening state. Repeat FS 57 at 5:00 PM. At 10:30 PM resident was alert and able to make needs known. Ambulated with assist to the bathroom then back to bed resting comfortably. During a telephone phone interview on 6/30/17 at approximately 11:45 AM, LPN #1 stated that the resident's FS at 5:30 PM on 6/23 was actually 43, not 57; she had entered it incorrectly on the MAR. Additional review of the medical record, including Nursing Progress Notes dated 6/23/17 revealed no documented evidence that an RN assessed the resident's condition on 6/23/17, when the FS' were 43 and 57. During a telephone interview on 6/30/17 at approximately 12:30 PM, the RN (#1) Manager/ Supervisor stated that on 6/23/17 at approximately 5:00 PM, LPN #1 informed her that Resident #1's FS was 57, and LPN #1 had contacted the NP who ordered no further insulin coverage the remainder of the shift. RN #1 stated she instructed LPN #1 to give orange juice and sugar via the [DEVICE] and re-check the FS in 20 minutes. RN #1 stated I looked in on the resident and he was a little sweaty and could answer yes or no. I didn't take his vital signs or pulse ox (oximetery- oxygen saturation level in the blood) or do any other assessments. RN #1 stated that LPN #1 informed her that Resident #1's FS went up, however she did not check on him later in the shift and she did not document the incident. Review of a Progress Note, written by the Social Worker, dated 6/26/17 at 1:59 PM revealed the resident was sent to the hospital on [DATE] and remained for observation. Further review of the Nursing Progress Notes dated 6/24/17 revealed there was no documentation as to why the resident was sent to the hospital. During an interview on 6/30/17 at 3:30 PM, the RN (#2) Supervisor who worked the 3:00 PM to 11:00 PM shift on 6/24/17 stated that she did not document the events leading to Resident #1 being sent to the hospital because I was busy, I only work part time and I planned to document on my first day back to work. RN #2 then stated I just documented a late entry for 6/24/17 at 8:30 PM prior to this interview, per the Director of Nursing's (DON) request. During an interview on 6/30/17 at 4:00 PM, the DON stated that her expectation of RN #2 was to document the events leading to Resident #1 being sent to the hospital, prior to going off duty on 6/24/17. During an interview on 7/11/17 at approximately 10:00 AM, the DON stated that her expectation of RN #1 was to perform a head to toe, side to side assessment. Vital signs (blood pressure, temperature, pulse, respiratory rate), neurological, cognition, respiratory, range of motion; all the systems and document her findings. During the interview the DON stated no additional information was available. 415.22(a)(1,2)

Based on interview and record review conducted during the Standard Survey completed on 9/13/16, the facility did not inform the resident's legal representative or interested family member when there is a significant change in the resident's physical, mental or psychological status. One (Resident #356) of two residents reviewed for notification of change had issues involving the lack of timely notification of the resident's family/responsible party regarding physician's orders [REDACTED]. The finding is: 1. Resident #356 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - assessment tool) dated 8/5/16 revealed the resident has severely impaired cognition. Review of a Nursing Progress Note, written by a licensed practical nurse (LPN) dated 8/24/16 at 3:02 PM revealed the resident had some emesis (vomit) during lunch. The LPN documented that the MD (medical doctor) ordered a stat (immediate) CBC (complete blood count - blood work), CMP (comprehensive metabolic profile - bloodwork) and an abdominal x-ray. Lab (laboratory) results did not come in yet, x-ray results came in, and MD was updated. She also gave new order for [MEDICATION NAME] (anti- nausea medication) IM (intramuscular injection) prn (as needed) for nausea, she is also on clear liquid diet for 24 hours and vital signs every shift for 48 hours. There was no documented evidence that a family member was updated about the new orders. Review of a Nursing Progress Note, written by an LPN, dated 8/24/16 at 9:40 PM revealed a voicemail was left with a medical provider group; the nurse practitioner (NP) returned the call;[MEDICATION NAME](antibiotic) was ordered for seven days; and the first dose was given from the ER (emergency) box. The LPN documented that a voicemail and message were left with the resident's daughter to return a call to the unit to update, No return call as of yet. At 10:37 PM, the LPN spoke with the daughter regarding the resident's status and the daughter was upset that no one called her during the day shift to update her regarding her mother. Daughter verbalized understanding of her mother's condition and antibiotic therapy. Review of a Nursing Progress Note, written by a registered nurse (RN), dated 8/24/16 at 10:56 PM revealed the RN spoke with resident's daughter at 10:30 PM and the daughter was very angry that she wasn't notified until 10:00 PM, that resident did not eat anything for lunch. During an interview on 9/7/16 at 12:51 PM, the resident's family member stated that there was a change in her mother's condition about two weeks ago; she was vomiting and not feeling well and they ordered some tests on her. I never found out until they notified me of the test results that she was sick. It bothered me that they didn't contact me right away, as I would have come right over here to check on her. During an interview on 9/9/16 at 10:55 AM, the RN (#7) Unit Manager stated that families get updated with any change in condition, changes in medication, or out of the norm labs (laboratory results). Families are aware of routine labs and any stats or x-rays they would be notified about. The nurse who is taking care of that resident is A: supposed to call the family when there's been a change in condition and B: tell them what they are going to do and that we will call you back with results. When asked if the nurses are supposed to document if they updated the family, the RN stated she should have documented it, that's our policy and that's the procedure. During an interview on 9/13/16 at 11:03 AM, the RN (#8) Assistant Director of Nursing (ADON) stated that families are usually updated right away, unless it's the middle of the night and yes the family should have been notified right away. Review of a facility Directive and Procedure entitled Resident Change of Condition dated 7/6/12 revealed the The physician will be notified by nurse of significant change and it will be documented in Nurses Notes. In addition, the resident's responsible party will be updated.

Based on interview and record review conducted during the Standard survey completed on 9/13/16, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. Two (Residents #51, 342) of 24 residents reviewed for care plan development had an issue with the lack of a comprehensive care plan to address histories of a urinary tract infection [MEDICAL CONDITIONS] ([MEDICAL CONDITION] - drug resisitant bacteria) in a leg wound (#51) and the use of an anticoagulant (blood thinning medication) (#342). The findings are: 1. Resident #51 has [DIAGNOSES REDACTED]. Review of the Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/15/16 revealed the resident has moderate cognitive impairment, usually understands, and is understood. Review of a Urine Culture Report dated 3/8/16 revealed a colony count of greater than 100,000 CFU/ ml Proteus Mirabilis (bacteria) indicating that the resident had a urinary tract infection. Review of the Annual MDS assessment dated [DATE] - Section I revealed the resident was treated for [REDACTED]. Review of a Wound Culture Report dated 7/22/16 revealed the left leg wound culture tested positive [MEDICAL CONDITION]. Review of the Comprehensive Care Plan (CCP), last revised 9/9/16, revealed the CCP did not identify that the resident was at risk for a urinary tract [MEDICAL CONDITION] infection. During an interview on 9/13/16 at 9:06 AM, the Registered Nurse (RN #6) Unit Manager stated the Comprehensive Care Plans are completed upon admission and updated quarterly and as needed when changes in conditions occur. The RN Unit Manager stated he did not realize that the CCP did not reflect the urinary tract infection or [MEDICAL CONDITION] infection in the residents wound. It should be included to reflect these problems. I will make the correction. During an interview on 9/13/16 at 10:03 AM, the Assistant Director of Nursing (ADON) stated she would expect that the Comprehensive Care Plan be developed on admission or when the resident has a change in condition. Urinary Tract Infections and a history [MEDICAL CONDITION] are expected be identified on the resident's Comprehensive Care Plan. Review of a Directive and Procedure entitled Assessment and Care Planning dated 6/2016 revealed the Nursing Department will do an initial evaluation of the resident's abilities, clinical, and psychosocial needs upon admission. The evaluation process is ongoing and therefore continues throughout the length of the stay. An ongoing intense resident evaluation continues through the collaborative efforts of all disciplines. The evaluation is a daily/shift event encompassing the following: Review of the Care Plan on an ongoing basis for any changes. Documentation of resident data is incorporated onto the care plan and in the medical record of the resident. 2. Resident #342 has [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].>Review of the current, undated Comprehensive Care Plan (CCP) revealed the resident was identified at moderate risk for falls and has a history of falls. Additional review of the CCP revealed there was no care plan developed for the use of an anticoagulant medication. Review of the Visual/Bedside Kardex Report, used by certified nurse aides (CNAs) to provide care, dated 9/9/16 revealed there were no precautionary interventions due to the use of Eliquis. During an interview on 9/9/16 at 11:30 AM, the RN (#4) Unit Manager stated there was no care plan for the use of Eliquis. 415.11(c)(1)

Based on interview and record review conducted during the Standard Survey completed on 9/13/16, the facility did not ensure the resident's right to participate in planning care and treatment or changes in care and treatment; and did not ensure that the comprehensive care plan is periodically reviewed and revised after each assessment. One (Resident #215) of twenty-four residents reviewed for care plans and care plan participation had an issue involving the lack of resident participation in care plan meetings. The finding is: 1. Resident #215 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/20/16 revealed the resident is cognitively intact, understands, and is understood. During an interview on 9/7/16 at approximately 11:37 AM, the resident stated I do not believe I have ever been invited to my care plan meetings. I think I would like to attend them. Review of the entire medical record, including Social Work Progress Notes for the past year, revealed no documented evidence that the resident was invited to or attending her care plan meetings. During an interview on 9/13/16 at approximately 8:45 AM, the Social Worker (SW #1) stated Medical Records takes care of inviting families and residents to the care plan meetings. They are only invited annually. I will write a note regarding whether the family and/or resident attended or did not attend the care plan meeting. I am fairly new to this unit and I was not here when Resident #215's annual meeting last took place. During an interview on 9/13/16 at approximately 8:50 AM, SW #2 stated The resident never comes out of her room and hasn't attended a care plan meeting since I have been here and that is at least six years. I have not documented that she does not attend the meetings or that I invited her to it. I usually do not document that. During an interview on 9/13/16 at approximately 9:08 AM, the Transcriptionist Interdisciplinary Secretary stated I keep a record of when the letters are sent out. A letter went out to the resident's daughter in February. I would send a letter to the resident, if I am told to. I cannot say whether I sent one out to the resident themselves. During an interview on 9/13/16 at approximately 9:18 AM, the Administrator stated I know the process is not that great and we are working on it. But, we do send letters out to the responsible parties. No we do not keep a copy of all the letters sent out, because that would be a lot of letters to have to keep on file. During an interview on 9/13/16 at 9:57 AM, Resident #215 stated That is correct, I have never been invited to my care plan meeting. I wish I was, because I have some things I would like to get changed on it. My daughter has never told me that she received a letter inviting her to my care plan meetings. She visits me often, but has never said anything to me. It bothers me that I have not been invited because like I had said, I would like to change some things on my care plan. Review of a facility Directive and Procedure entitled MDS and Care Planning dated 12/17/15 revealed an invitation to the annual care plan meeting is mailed to the resident and/or the family. Review of a Directive and Procedure entitled Interdisciplinary Care Planning dated 8/6/14 revealed meetings are scheduled weekly in each neighborhood. Residents are invited according to schedule. 415.11(c)(2)(ii)

Based on interview and record review conducted during the Standard survey completed on 9/13/16, the facility did not conduct a comprehensive assessment using the Resident Assessment Instrument (RAI) specified by the State for a resident with a significant change in condition. One (Resident #51) of three residents' RAIs reviewed did not have a Significant Change Assessment completed within seven days of a significant change in condition. The finding is: 1. Resident #51 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/15/16 revealed the resident has moderate cognitive impairment, usually understands, and is understood. Review of the Clinical - MDS screen on 9/9/16 revealed a Quarterly MDS dated [DATE] and an Annual MDS dated [DATE], with the status of accepted. Review of the Quarterly MDS dated [DATE] revealed Section G - ADL (activities of daily living) Assistance revealed the following: A) Bed Mobility: (how resident moves to and from lying position, turns side to side, and positions body while in bed: requires an extensive assist of two staff members B) Transfer: (how resident moves between surfaces including to or from bed, chair, wheel chair, standing position): requires total assist with assist of two. C) Walk in Room- activity did not occur. D) Walk in Corridor- activity did not occur. E) Locomotion on unit- how resident moves between locations in his/her room- Supervision, set up help only F) Locomotion off unit- how resident moves to and returns from off unit locations- activity did not occur. G) Dressing- how residents puts on, fastens and takes off all items of clothing- Total dependence with assist of one staff member. H) Eating- how resident eats and drinks, regardless of skill- resident Independent with set up help only. I) Toilet use- how the resident uses the toilet room- Total dependence with assist of one staff member. J) Personal Hygiene- how resident maintains personal hygiene- Extensive assist of one staff member. Review of Section I - Active [DIAGNOSES REDACTED]. Review of Section K - Swallowing/ Nutrition on the MDS dated [DATE] revealed the resident weighed 167 pounds (lbs). Review of a Social Work Progress Note dated 1/29/16 revealed the resident had a new [DIAGNOSES REDACTED]. Review of an IDT (Interdisciplinary Team) Progress Note dated 2/18/16 labeled Special Review to discuss resident's weight loss revealed the resident weighed 157.7 Ibs as of February 2016, suggesting further weight loss and a significant weight loss x one month, three months and six months. The Progress Note documented that the resident demonstrated an approximate 9 Ib weight loss from 1/20/16 through 2/12/16 and there were no changes to his medications to attribute to his weight loss. The resident only eats two meals per day, has been needing increased assistance at meals, and has decreased self-feeding ability with the use of utensils during mealtimes. Review of the Annual MDS dated [DATE] revealed that Section G - ADL Assistance documented the following: A) Bed Mobility: requires an extensive assist of two staff members. B) Transfer: requires total assist with assist with two staff members. C) Walk in Room: activity did not occur D) Walk in Corridor: activity did not occur E) Locomotion on unit: requires extensive assist with the help of one staff member F) Locomotion off unit: requires extensive assist with the help of one staff member G) Dressing: requires extensive assist with the help of two staff members H) Eating: requires extensive assist with the help of one staff member I) Toilet use: total dependence with assist of one staff member J) Personal Hygiene: requires extensive assist of one staff member Additional review of Section K - Swallowing/ Nutrition of the MDS dated [DATE] revealed the resident weighed 147 Ibs, a difference of 20 Ibs since the previous assessment. This was coded on the MDS as a loss of 5% or more in the last month or a loss of 10% or more in the last six months. Further review of the MDS revealed the resident had a decline in ADL's from an extensive assist to a total assist with dressing and from independent with eating to an extensive assist of one staff member for meals, a significant weight loss, and a new [DIAGNOSES REDACTED]. Review of a facility Directive and Procedure labeled MDS and Care Planning dated 2/14/01 revealed if a change has occurred in a resident or a change of care is indicated, any member of the IDT (interdisciplinary team) can send a request to the Clinical Operations Department for review and determination with the IDT if a significant change assessment per the RAI Manual guidelines should be initiated. If a significant change is indicated the IDT, then the Director of Clinical Operations will initiate the completion of a significant change MDS. Review of the RAI (Resident Assessment Instrument) 3.0 Manual revealed a Significant Change in Status Assessment (SCSA) must be completed when the IDT has determined that a resident meets the significant guidelines for improvement or decline. A significant change is a decline or improvement in a resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions; is not self-limiting (for declines only); impacts more than one area of the resident's health status; and requires IDT review and/or revision of the care plan. The SCSA is appropriate when there is a determination that a significant change in a resident's condition from his/ her baseline has occurred by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly Assessments and the resident's condition is not expected to return to baseline within two weeks. A SCSA is appropriate if there are two or more areas of decline or two or more areas of improvement. Decline in two or more of the following: - Resident's decision making changes - Any decline in ADL physical functioning area where the resident is newly code as Extensive assist - Total dependence or Activity did not occur since last assessment - Emergence of unplanned weight loss problem (5% change in 30 days, or 10% change in 180 days) - Emergence of a new pressure ulcer at Stage II or higher or worsening in pressure ulcer status. During an interview with the LPN (#2) MDS Nurse on 9/13/16 at 9:36 AM revealed that the MDS Nurses to do not participate in the care planning process and just complete the MDS assessment. If there are changes with the resident's condition, the staff are to notify her or the Director of Clinical Operations would notify her after morning report if she noted that any changes have occurred in someone's baseline and then she would determine if a SCSA is required. Interview with the Director of Clinical Operations on 9/13/16 at 10:38 AM revealed that communication with the IDT occurs at morning report, but if information is not shared then it tends to be missed. I would expect the Unit Manager to notify me if such changes occur so I can review the information. During an interview on 9/13/16 at 10:03 AM, the ADON (Assistant Director of Nursing) stated I would expect my team to have done a significant change in status assessment between the Quarterly assessment in January and the Annual assessment in April. There was a weight loss recognized with a decline in ADL's. I'm not so sure about the new [DIAGNOSES REDACTED]. 415.11(a)(3)(ii)

Based on observation, interview and record review conducted during a Complaint investigation (Complaint #NY 311) during an Abbreviated survey completed on 5/23/16, the facility did not ensure that a resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. One (Resident #1) of 3 residents reviewed for quality of care lacked a timely assessment by a Registered Professional Nurse (RN) when the resident had a significant change in condition of a newly identified left thigh blister for 10 days. In addition, the left thigh blister that lacked weekly skin monitoring and a physician ordered treatment became infected with polymicrobial (multiple bacteria) in nature with [MEDICAL CONDITIONS], many E. Coli (bacteria), and many Pseudomonas Aeruginosa (bacteria) that required surgical intervention and hospitalization for one week. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimun Data Set (MDS-a resident assessment tool) dated 12/8/15 revealed the resident is cognitively intact. Review of a facility policy and procedure entitled Skin Interruption Monitor Protocol-Non Pressure Related dated 2/9/11 revealed a skin interruption is any alteration in skin integrity that is not a result of pressure over bony prominence or sustained pressure from an extreme force (splint, brace, bedrail). Residents with skin interruptions will be monitored and documented weekly and prn (as needed) on Skin Condition, Monitoring Assessment Form. The Procedure includes but is not limited to the following: -When the Unit Manager or designee is aware of any skin abnormalities the area is to be assessed and documented Skin Condition Monitoring Assessment Form. -Documentation with measurements of skin interruption must occur upon identification on the shift on which the skin interruption was identified (or determined by the RN Unit Manager) and weekly. -Physician orders [REDACTED]. -Skin interruptions to be measured include any wound determined by an RN to require measurements. Review of a Care Plan Historical Copy dated 12/10/15 revealed the resident is at risk for skin breakdown due to incontinence of urine, restricted mobility and dry skin. Review of a Care Plan Historical Copy dated 1/4/16 revealed the resident has [MEDICAL CONDITION] (inflammation of tissue under skin) to right shin with a plan to administer antibiotics, observe for side effects and effectiveness and report concerns/worsening symptoms to physician promptly. Interventions include air mattress and float heels in bed at all times. Assist with mobility as directed. Encourage and assist with frequent position changes. Review of an Interdisciplinary Note dated 1/23/16 at 2:21 PM written by a Licensed Practical Nurse (LPN) #1 revealed that the resident was quite confused and disoriented this morning and had to be redirected a few times. Complained of pain in his left leg and buttock. Pain medication given with positive effect. Review of an Interdisciplinary Note dated 1/23/16 written by LPN #2 at 10:54 PM revealed the resident seemed anxious. Resident has some confusion and slower to respond to questions. Area around left lower extremity cellulitus wound very warm to touch. MD (medical doctor) notified. T (temperature-normal 98.6 F- Fahrenheit) 100.6, AP (apical pulse-heart rate obtained by listening with a stethoscope on the chest; average 80) 84, R (respirations-normal 12-20) 18, BP (blood pressure-normal 120/80) 170/90. New orders included urine C&S (culture and sensitivity), Keflex (antibiotic), [MEDICATION NAME] (narcotic pain medication), Tylenol (pain medication). Family updated. Review of Interdisciplinary Notes dated 1/24/16 written by the RN Assistant Director of Nursing (ADON )/Skin Supervisor at 3:39 PM revealed she was in to see the resident's left lower leg. While in the room with the wife, the resident complained of discomfort in the upper left leg. A bandaid was removed to reveal a 1 centimeter (cm) x (by) 2 cm open area with a green/yellow base with red edges and red peri (around) wound. Spoke with MD and updated her on the area on the left upper leg, a wound culture was ordered and wife updated. Review of Interdisciplinary Notes dated 1/24/16 at 6:31 PM written by LPN #3 revealed the resident's wife voiced concern regarding resident's constant pain in the left lower leg and requested an x-ray. MD notified and ordered stat (immediate) x-ray of left lower extremity and stat Doppler (diagnostic test to evaluate blood circulation) of both lower extremities, and wound culture of upper left thigh wound. On 1/24/16 treatment started to cleanse the wound with wound cleanser, pat dry, apply with TAO (triple antibiotic ointment) and cover with dry clean dressing, wrap with Kerlix (sterile gauze dressing used to wrap wounds) every eight hours. Resident taken to hospital on [DATE] at 6:00 PM per MD order and family request. Review of the upper left thigh wound Bacteriology Final Report (obtained on 1/24/16) dated 1/28/16 revealed the cultures were polymicrobial (multiple bacteria) in nature with [MEDICAL CONDITION], many E. Coli, many Pseudomonas Aeruginosa. Review of the Hospital Discharge Summary dated 1/30/16 revealed the resident presented to the emergency department, febrile with mild [MEDICAL CONDITION](rapid heart rate). Extremity left medial thigh: unstageable ulcer with purulent (containing/forming pus)yellowish discharge, some surrounding [DIAGNOSES REDACTED] (reddness) and swelling. He was evaluated by both Infection Control and surgery and underwent incision and drainage of a left thigh abscess on 1/26/16. Review of a facility investigation into the development of the resident's left thigh abscess dated 2/2/16 revealed the following: -On 1/14/16 LPN #4, who works the 11:00 PM to 7:00 AM shift noted a small fluid filled blister on upper left thigh and placed a bandaid on the area and passed it on in report to LPN #5. LPN # 4 did not write a Nurse's Note and did not send out a skin notice per work standards of the facility. -On 1/15/16 LPN #5 forgot to pass along to her RN Nurse Manager (NM) about the area (on the resident's left thigh). LPN #2 was to complete a skin check for the resident and signed for the skin check but failed to follow proper procedure and complete the skin monitoring sheet. LPN #2 stated she saw the bandaid but does not remove treatments if they are not for her shift. -On 1/19/16 the LPN # 5 did a skin check on the resident but per her statement did not do a thorough one. -On 1/22/16 LPN #1 was to do a skin check on the resident but failed to sign that she completed it as well as failed to fill out the skin monitoring sheet. When asked, LPN #1 stated she does do her skin checks, she just did not sign for it. Review of a Skin Check Monitoring Sheet revealed skin checks were completed on 1/5/16, 1/12/16 and 1/19/16 with no new skin issues noted. Review of the Treatment Administration Record (TAR) for January 2016 revealed the resident is to receive a skin check twice a week with weekly bath on Tuesday and Friday. Further review of the TAR revealed no documentation for 1/8/16 or 1/22/16 that the resident received a bath or skin check on those dates. Interview by phone was conducted on 5/20/16 at approximately 8:15 AM with LPN #4. During the interview, LPN #4 stated he was the full time 11:00 PM to 7:00 AM Charge Nurse on the unit and stated he observed a small fluid filled blister on the resident's upper left thigh on 1/14/16. LPN #4 said he cleaned the area with normal saline (NS), applied TAO and placed a bandaid over the blister. The resident did not report any pain at this time and the resident did not have the left thigh blister the day before. LPN #4 reported the new blister to LPN #5 at the change of shift. LPN #4 revealed he did not complete any documentation including Nurse's Notes or the skin notification as he was tied up. When asked if he notified the RN Supervisor, LPN #4 said, no. When asked if he looked at the blistered area any time after he first discovered it, LPN #4 stated if the band aid was off or soiled he would cleanse the area with NS, apply TAO and replace the bandaid. LPN #4 stated he did not document anything about the blistered area or the treatments provided. During an interview with LPN #1 on 5/18/16 at approximately 2:00 PM, LPN #1 stated she did her skin check on 1/22/16 but did not see the bandaid. The resident did not have any complaints. LPN #1 also stated she was aware of the skin monitoring protocol. During an interview on 5/19/16 at approximately 10:00 AM, the resident stated that his left upper thigh had been sore before he went to the hospital but was better now. Observation of the resident's upper left thigh at this time revealed the wound was healed. During an interview with LPN #5 on 5/18/16 at approximately 2:00 PM, revealed LPN #5 did receive report from LPN #4 regarding the new blister on Resident #1's left thigh and was asked to pass the information on to the Nurse Manager. In addition, LPN #5 stated LPN #4 said he was monitoring the area on the left thigh. LPN #5 stated she was aware of the skin monitoring protocol. During an interview on 5/20/16 at approximately 1:00 PM, the ADON/Skin Supervisor, that makes weekly skin rounds, stated that she first learned of the open area located on the resident's left thigh when she removed the bandaid covering the area (1/24/16). Further interview with the ADON/Skin Supervisor revealed nursing staff are inserviced at least twice a year on the skin monitoring protocol in addition to some informal education. When asked what her expectation was with regard to assessment of a significant change of condition, the ADON/Skin Supervisor responded as soon as a skin interruption is noted there should be documentation in the Nurse's Notes and in the skin note template. Phone interview with the Attending Physician/Medical Director on 5/20/16 at approximately 2:00 PM revealed prior to Resident #1's discharge to the hospital on [DATE] the Attending Physician/Medical Director was not aware of the development of a blister on the resident's left thigh and subsequent development of an abscess. When asked what her expectation is in this type of situation the Attending Physician/Medical Director stated, follow the protocol. The Administrator stated on 5/18/16 at approximately 2:00 PM that his expectation is that the nursing staff follow the Skin Interruption Monitor Protocol-Non Pressure Related and Preventive Skin Care policy and procedure. 415.12

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 10/8/15. Based on observation, interview and record review conducted during a Complaint investigation (Complaint #NY 311) during an Abbreviated survey completed on 5/23/16, the facility did not consult with the resident's Physician when there is a significant change in the resident's physical, mental, or psychosocial status or a need to alter the resident's treatment. One (Resident #1) of 3 residents reviewed for notification of change had issues with the lack of Physician notification of a newly developed left thigh blister for 10 days. In addition, the left thigh blister that lacked a physician ordered treatment became infected [MEDICAL CONDITIONS], E.Coli (bacteria), and Pseudomonas Aeruginosa (bacteria) that required surgical intervention and hospitalization for one week. The finding is: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimun Data Set (MDS-a resident assessment tool) dated 12/8/15 revealed the resident is cognitively intact. Review of a facility policy and procedure entitled Skin Interruption Monitor Protocol-Non Pressure Related dated 2/9/11 revealed a skin interruption is any alteration in skin integrity that is not a result of pressure over bony prominence or sustained pressure from an extreme force (splint, brace, bedrail). The Procedure included that Physician orders [REDACTED]. Review of a Care Plan Historical Copy dated 12/10/15 revealed the resident is at risk for skin breakdown due to incontinence of urine, restricted mobility and dry skin. Review of a Care Plan Historical Copy dated 1/4/16 revealed the resident has [MEDICAL CONDITION] (inflammation of tissue under skin) to right shin with a plan to administer antibiotics, observe for side effects and effectiveness and report concerns/worsening symptoms to physician promptly. Interventions include air mattress and float heels in bed at all times. Assist with mobility as directed. Encourage and assist with frequent position changes. Review of an Interdisciplinary Note dated 1/23/16 at 2:21 PM written by a Licensed Practical Nurse (LPN) #1 revealed that the resident was quite confused and disoriented this morning and had to be redirected a few times. Complained of pain in his left leg and buttock. Pain medication given with positive effect. Review of an Interdisciplinary Note dated 1/23/16 written by LPN #2 at 10:54 PM revealed the resident seemed anxious. Resident has some confusion and slower to respond to questions. Area around left lower extremity cellulitus wound very warm to touch. MD (medical doctor) notified. T (temperature-normal 98.6 F- Fahrenheit) 100.6, AP (apical pulse-heart rate obtained by listening with a stethoscope on the chest; average 80) 84, R (respirations-normal 12-20) 18, BP (blood pressure-normal 120/80) 170/90. New orders included urine C&S (culture and sensitivity), Keflex (antibiotic), [MEDICATION NAME] (narcotic pain medication), Tylenol (pain medication). Family updated. Review of Interdisciplinary Notes dated 1/24/16 written by the RN Assistant Director of Nursing (ADON )/Skin Supervisor at 3:39 PM revealed she was in to see the resident's left lower leg. While in the room with the wife, the resident complained of discomfort in the upper left leg. A bandaid was removed to reveal a 1 centimeter (cm) x (by) 2 cm open area with a green/yellow base with red edges and red peri (around) wound. Spoke with MD and updated her on the area on the left upper leg, a wound culture was ordered and wife updated. Review of Interdisciplinary Notes dated 1/24/16 at 6:31 PM written by LPN #3 revealed the resident's wife voiced concern regarding resident's constant pain in the left lower leg and requested an x-ray. MD notified and ordered stat (immediate) x-ray of left lower extremity and stat Doppler (diagnostic test to evaluate blood circulation) of both lower extremities, and wound culture of upper left thigh wound. On 1/24/16 treatment started to cleanse the wound with wound cleanser, pat dry, apply with TAO (triple antibiotic ointment) and cover with dry clean dressing, wrap with Kerlix (sterile gauze dressing used to wrap wounds) every eight hours. Resident taken to hospital on [DATE] at 6:00 PM per MD order and family request. Review of the upper left thigh wound Bacteriology Final Report (obtained on 1/24/16) dated 1/28/16 revealed the cultures were polymicrobial (multiple bacteria) in nature with [MEDICAL CONDITION], many E. Coli, many Pseudomonas Aeruginosa. Review of the Hospital Discharge Summary dated 1/30/16 revealed the resident presented to the emergency department, febrile with mild [MEDICAL CONDITION](rapid heart rate). Extremity left medial thigh: unstageable ulcer with purulent (containing/forming pus)yellowish discharge, some surrounding [DIAGNOSES REDACTED] (reddness) and swelling. He was evaluated by both Infection Control and surgery and underwent incision and drainage of a left thigh abscess on 1/26/16. Review of a facility investigation into the development of the resident's left thigh abscess dated 2/2/16 revealed the following: -On 1/14/16 LPN #4, who works the 11:00 PM to 7:00 AM shift noted a small fluid filled blister on upper left thigh and placed a bandaid on the area and passed it on in report to LPN #5. LPN # 4 did not write a Nurse's Note and did not send out a skin notice per work standards of the facility. -On 1/15/16 LPN #5 forgot to pass along to her RN Nurse Manager (NM) about the area (on the resident's left thigh). Review of a Skin Check Monitoring Sheet revealed skin checks were completed on 1/5/16, 1/12/16 and 1/19/16 with no new skin issues noted. Review of the Treatment Administration Record (TAR) for January 2016 revealed the resident is to receive a skin check twice a week with weekly bath on Tuesday and Friday. Further review of the TAR revealed no documentation for 1/8/16 or 1/22/16 that the resident received a bath or skin check on those dates. Review of the Interdisciplinary Notes revealed no documented evidence that the Attending Physician/Medical Director was notified of the resident's left thigh blister identified on 1/14/16 until 1/24/16. During an interview on 5/19/16 at approximately 10:00 AM, the resident stated that his left upper thigh had been sore before he went to the hospital but was better now. Observation of the resident's upper left thigh at this time revealed the wound was healed. Interview by phone was conducted on 5/20/16 at approximately 8:15 AM with LPN #4. During the interview, LPN #4 stated he was the full time 11:00 PM to 7:00 AM Charge Nurse on the unit and stated he observed a small fluid filled blister on the resident's upper left thigh on 1/14/16. LPN #4 reported the new blister to LPN #5 at the change of shift. LPN #4 revealed he did not complete any documentation including Nurse's Notes or the skin notification as he was tied up. When asked if he notified the Registered Nurse (RN) Supervisor, LPN #4 said no. During an interview on 5/20/16 at approximately 1:00 PM, the ADON/Skin Supervisor, that makes weekly skin rounds, stated that she first learned of the open area located on the resident's left thigh when she removed the bandaid covering the area (1/24/16). When asked what her expectation was with regard to Physician notification of the left thigh blister, the ADON/Skin Supervisor responded as soon as a skin interruption is noted the RN and Physician should have been notified for treatment orders. Phone interview with the Attending Physician/Medical Director on 5/20/16 at approximately 2:00 PM revealed prior to Resident #1's discharge to the hospital on [DATE] the Attending Physician/Medical Director was not aware of the development of a blister on the resident's left thigh and subsequent development of an abscess. When asked what her expectation is in this type of situation the Attending Physician/Medical Director stated, follow the protocol. 415.3 (e)(2)(ii)(c)