Every finding on record at Bishop Rehabilitation and Nursing Center

Based on record review and interviews, the facility failed to ensure a resident received adequate supervision to prevent accidents. Specifically, on 05/03/2026, Resident #1 was visiting another resident on a different nursing unit. Licensed Practical Nurse #8 misidentified the resident as a visitor and escorted them out of the building at 2:00 AM. Staff on the resident's unit were not aware the resident was missing until 7:00 AM. On 05/03/2026 at approximately 11:00 AM, a former employee recognized the resident at an event approximately three miles from the facility and returned the resident to the facility. The resident sustained an abrasion to their head and hand, was disoriented, and had soiled clothing due to incontinence. This resulted in harm to Resident #1 that was Immediate Jeopardy and Substandard Quality of Care and placed all residents at risk for serious harm, serious injury, serious impairment, or death. The facility policy titled, Safety and Supervision of Residents dated 02/01/2024 documented the facility will identify resident risk factors based on the facility's resident population. Action plans will be implemented which may include but not be limited to resident specific and resident centered interventions, supervision or assistive device use, temporary or permanent modification of the environment, resident/resident representative education and staff education. Resident #1 had diagnoses of unspecified dementia with mood disturbance (brain-related memory loss and thinking decline) major depressive disorder (an on-going sadness or loss of interest) and need for assistance with personal care (hands-on supportive care with daily tasks). The 02/20/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, required supervision/touch assistance for bathing, was independent with toileting hygiene and personal hygiene and was independently mobile. The Comprehensive Care Plan initiated 05/23/2025 documented Resident #1 required assistance with self-care and mobility related to confusion and dementia and had limited physical mobility related to dementia. Interventions included: encourage resident to participate to the fullest extent possible with each interaction; encourage use of call bell for assistance; and the resident walked independently. The Resident Care Instructions documented ensure call bell is available for safety issues, urinary toileting care every 2-4 hours as indicated and as tolerated during waking hours and as needed, bowel toileting care every 2-4 hours as indicated as tolerated during waking hours and as needed, check for toileting needs, provide incontinence care as needed and distract resident from wandering by offering pleasant diversions. Record reviews and interviews conducted during revealed: - during the 11:00 PM-0700 AM shift, Resident #1 was on Unit A South visiting Resident #4. - at 2:00 AM, Licensed Practical Nurse #8 misidentified Resident #1 as a visitor, asked their name and advised them visiting hours were over. Licensed Practical Nurse #8 escorted the resident from the building. - at 07:00 AM, Licensed Practical Nurse Unit Manager #17 received report that Resident #1 was missing and called 911 to report that the resident was missing. - at approximately 11:00 AM-12:00 PM, a former staff member (Registered Nurse #15) observed Resident #1 having an altercation with the police 2.6 miles away from the facility, went across the street and informed the police they recognized them as a missing resident and returned the resident to the facility. Registered Nurse #15 stated Resident #1 was cold, hungry, incontinent of bowel and bladder and disoriented. Upon arrival to the facility, Registered Nurse #15 accompanied the resident to the front lobby and assisted the Administrator, Registered Nurse #2 and two unnamed supervisors with placing a wandering device on the resident and then Registered Nurse #15 exited the facility.The 05/3/2026 police report documented they received a 7:24 AM dispatch to the facility for a missing person. Upon arrival to the facility, Licensed Practical Nurse #17 informed them Resident #1 was discovered missing at 7:00AM and they phoned 911. The responding police officer conducted additional employee interviews, and it was determined that Resident #1 was escorted from the building at 2:00 AM by Licensed Practical Nurse #8. The police officer conducted a search of the community and was advised around approximately 11:00 AM that Resident #1 was returned to the facility. The responding police officer returned to the facility, observed the resident in good health and the resident could not recall the events of what happened to them. There was no documented evidence of nursing progress notes to indicate Resident #1 had gone missing from the facility. The 05/03/2026 untimed facility investigation conclusion documented Resident #1 visited Resident #4 on Unit A South at 2:00 AM. Licensed Practical Nurse #8 misidentified Resident #1 as a visitor, asked them to leave and escorted the resident to the side employee door and out of the facility. Resident #1 was not discovered missing until 7:00 AM. A Code Grey (missing resident code) was initiated, and a facility wide search was completed and 911 was phoned. Resident #1 was found 1 mile away at a festival and upon return to the facility, had a quarter-sized abrasion to their scalp and a cut to their fingers. The resident was sent to the hospital per family request to be evaluated. The 05/03/2026 at 11:05 AM nursing progress note by Registered Nurse #6 documented the resident was assessed upon return to the facility, had an abrasion to their right ring finger and an abrasion to the top of their scalp. Family was at the bedside and requested the resident be sent to the Emergency Department for evaluation. The 05/03/2026 at 12:35 PM nursing progress note by Licensed Practical Nurse Unit Manager #23 documented a change in condition evaluation. Positive findings were increased confusion and general weakness. Recommendation was to send to the Emergency Department for evaluation. The 05/03/2026 at 2:04 PM nursing progress note by License Practical Nurse Unit Manager #23, documented Resident #1 returned with no new orders. Resident #1 had an abrasion to their scalp measuring 2.5 centimeters long by 0.5 centimeters wide by 0.1 centimeters deep. Treatments were in place. The 05/08/2026 at 6:09 AM Physician #14 progress note documented Resident #1 was seen for an elopement evaluation. Resident #1 could state their name and place but could not recall the time or year, had left the facility and was found downtown at a crawfish festival. The resident had a wound to their head with missing skin and hair on their scalp and stated they were hit in the head with a bamboo stick by a [NAME] artist and did not engage them. Physician #14's assessment and plan were to increase monitoring for exit-seeking behaviors, notify family representative of event, cleanse and apply topical wound care to the resident's head and monitor for signs and symptoms of infection. On 07/13/2026 at 10:00AM, Resident #1 was observed laying on their bed. Resident #1 could not recall the events of the incident on 05/03/2026. They stated they remembered walking up the street and had to go check on someone. Resident #1 stated they saw the police and trusted them, and someone told them they had to return to the facility. During an interview on 07/13/2026 at 2:56 PM, Resident #1's family representative stated they received a call to inform them their relative was missing. They made a post on social media to assist others in helping to locate the resident. The family representative called the facility to inquire what happened and was told by an unnamed staff member that the resident was escorted outside by a staff member and 911 was called. During an interview on 07/13/2026 at 3:25 PM, former employee (Registered Nurse #15) stated they observed Resident #1 having an altercation with police approximately 2.6 miles away from the facility and informed police the resident was missing from the facility. Registered Nurse #15 stated the resident was cold, hungry, was incontinent of bowel and bladder and disoriented. They escorted the resident back to the facility and brought them in the front door into the lobby. The Administrator, Registered Nurse #2 and two unnamed supervisors were present upon the return. During an interview on 07/13/2026 at 4:10 PM, Licensed Practical Nurse #8 stated they observed Resident #1 in Resident #4's room at 2:00 AM. They assumed Resident #1 was a visitor, looked in the computer [electronic medical record program] twice to identify them and their search did not reveal the resident. They informed Resident #1 that visiting hours were over and escorted them to the first-floor employee exit door on the side of the building. During an interview on 07/14/2026 at 11:00 AM, Registered Nurse #18 stated the nurses and certified nurse aides were taught how to identify a resident in the electronic medical record software. They did not know if house wide education was conducted on how to identify a resident versus a visitor if the person did not have an identification wristband or badge. Residents were allowed to enter the elevator and visit other units. The unit charge nurses were responsible for knowing where the residents were and there was supposed to be a sign out-sheet at the desk for them to sign or the nurse could call the other unit to let them know the resident was going there . There was no documented evidence of unit sign-out sheets or that Resident #1 signed out of their unit or into Resident #4's unit.During an interview on 07/14/2026 at 11:03 AM, Certified Nurse Aide #7 stated they worked on 05/03/2026 during the 11:00 PM to 7:00 AM shift on Unit A South. At 11:10 PM, they observed Resident #1 in Resident #4's room and were unfamiliar with them so they alerted Licensed Practical Nurse #8. During their second rounds at 2:00 AM, Resident #1 continued to be in Resident #4's room and they alerted Licensed Practical Nurse #8 again. Certified Nurse Aide #5 was present and told Licensed Practical Nurse #8 they thought the person was a resident but was not sure what unit they were from. Certified Nurse Aide #7 suggested they notify the supervisor and Licensed Practical Nurse #8 did not want to call them, as there was only one supervisor on duty. They stated Licensed Practical Nurse #8 looked up the resident in the computer and said they thought they were from a nearby in-patient substance use treatment facility. The nurse went into the room and then Resident #1 came out into the hall. Resident #1 appeared confused and did not know where to go. Certified Nurse Aide #7 stated they did not call anyone or say anything else due to observing the resident get on the elevator with Licensed Practical Nurse #8. They thought the nurse was returning the resident to their unit. During an interview on 07/14/2026 at 11:26 AM, Certified Nurse Aide #4 stated they worked the 11:00 PM to 7:00 AM shift on Unit C North. They were assigned to Resident #1, observed the resident on the Unit A South upon entering the facility and knew they were on another unit. Resident #1 always went to the Unit A South and it was not unusual for the resident to be away from their room at night. The resident usually sat down at the C North Unit nursing station. Certified Nurse Aide #4 stated during their last round at 5:00 AM, they thought Resident #1 was in bed because their room privacy curtain was pulled but they did not enter the room. During an interview on 07/14/2026 at 1:26 PM, Licensed Practical Nurse #9 stated they were assigned to work on 05/03/2026 from 11:00 PM to 7:00 PM on Units C North and C South. Licensed Practical Nurse #9 stated they observed Resident #1 on the Unit A South when they entered the facility at 11:00 PM at the start of their shift. They asked the resident if they were okay or needed anything and the resident replied no. They were primarily stationed on Unit C South during the night and did not check on Resident #1. They stated they relied on the aides to inform them if a resident was not in their room. During an interview on 07/14/2026 at 2:24 PM, Certified Nurse Aide #5 stated they worked on Unit A South on 05/02/2026 3:00 PM to 11:00 PM, and then 05/03/2026 on the 11:00 PM to 7:00 AM shift and observed Resident #1 on the unit since 3:00 PM. They informed Licensed Practical Nurse #8 the person in with Resident #4 was a resident, but they were unsure what floor they lived on. They assumed the nurse called other units to find out where the resident lived. Certified Nurse Aide #5 was not aware Resident #1 went missing until the morning at the end of the night shift, Licensed Practical Nurse #8 made a comment they escorted the resident out of the building around 2:00 AM. During an interview with the Medical Director on 07/15/2026 at 10:10 AM, they stated they were notified of the 05/03/2026 event following Resident #1's return to the facility. The resident initially went to the hospital emergency room for evaluation. The Medical Director saw the resident the following day, on 05/04/2026. The resident was unable to provide an account of what happened, due to short-term memory loss and confusion. They had a laceration on the top of their head, near the crown, approximately 1.5 centimeters. It was bandaged and the resident said someone hit them with a bamboo stick, they had pain at the site of the wound. The Medical Director was not notified the resident was escorted out of the building at 2:00 AM. They thought the resident walked out the door and was mistaken for a visitor. The resident was placed at risk due to the facility lacking a process to identify residents and that staff had not checked on the resident's whereabouts when they were not in their room at 2:00 AM.During an interview with the Administrator on 07/15/2026 at 11:30 AM, they stated if a resident leaves the building, they sign out at the front desk. Residents are identified by identification bracelets worn on their wrists, provided upon admission. If they prefer not to wear one, it could be a problem and documented in the electronic medical record. The facility's procedure for identification of residents includes asking their name, looking in the electronic medical record, looking at identification bracelets, asking a colleague, or looking up their picture. If an identification bracelet is missing or illegible, staff would have a conversation with the person and speak to colleagues to identify them. When Resident #1 was escorted out of the building, the Administrator was unsure if they had an identification bracelet at the time. The incident occurred due to the failure of Licensed Practical Nurse #8 to follow facility processes. Staff were expected to complete rounds every 2 to 4 hours and know they can communicate with other staff on other units if needed. During a follow up interview on 07/17/2026 at 10:30 AM, the Administrator stated they did not recall the statement from formerly employed Certified Nurse Aide #4, which included the aide did not enter Resident #1's room to observe them during the night or that Certified Nurse Aide #5 informed License Practical Nurse #8 that Resident #1 was a resident from another unit. Certified Nurse Aide #4 would have been terminated at the time, however they resigned from their position shortly following the incident. 10 NYCRR 415.12(h)(1)(2)___________________________________________________________________The Administrator was notified of Immediate Jeopardy on 07/15/2026 at 5:03 PM. The Administrator was notified on 07/17/2026 at 4:00 PM Immediate Jeopardy was lifted as of 07/16/2026 at 5:00 PM.The facility completed the following corrective actions:- Facility leadership conducted a resident audit and name bracelets were applied to any resident who was without one - Resident photos in Point Click Care (the electronic medical records software) were validated as current and updated if needed - Facility visitor Advanced Entry System will be utilized for all visitors signing in and out of facility - Visitors will be educated the badge must be prominently worn while in the facility via electronic communication to all resident contacts and a sign at the front desk - Sign in and out books created on all units for residents leaving and returning to the unit - End of shift resident head count will be conducted - As of 07/16/2026 at 5:00 PM, 90% of all facility staff received education on: Supervision of residents on and off the units and throughout the facility; resident identification including name bracelets and pictures in Point Click Care (an electronic medical record software); residents signing in and out of unit; Advanced Entry System for Visitors - all visitors must sign in and out and wear their badge at all times while in the facility; and resident head count at end of shift.- Any staff on leave, per diem, or not scheduled will receive education prior to the start of their shift. - Onsite verification of staff education via interviews with staff, training attendance sheets, and all staff education tracking sheet. - Onsite observations of visitor entrance, sign in, and identification badge process.- Onsite verification of newly implemented processes (unit sign out books, head count sheets, signage for visitors, residents with identification bands)- Residents who declined to wear an identification bracelet had care plans to reflect their wishes.

Based on record review and interviews, the facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Specifically, on 05/03/2026 at 2:00 AM, Resident #1 was misidentified as a visitor and escorted out of the facility by Licensed Practical Nurse #8 who did not verify the resident's identification prior to escorting them out. The facility was unaware Resident #1 was missing until 7:00 AM, and the resident was found at approximately 11:00 AM with an abrasion to their head, hand, and wearing soiled clothing due to incontinence. Findings include:The facility policy titled, Safety and Supervision of Residents dated 02/01/2024 documented the facility will identify resident risk factors based on the facility's resident population. Action plans will be implemented which may include but not be limited to resident specific and resident centered interventions, supervision or assistive device use, temporary or permanent modification of the environment, resident/resident representative education and staff education.The facility policy titled, Abuse revised 07/18/2025 documented the facility prohibits the mistreatment, neglect and abuse of residents/patients by anyone including but not limited to staff, family, friends and residents of the facility. Identify, correct and intervene in situations where abuse/neglect/misappropriation are more likely to occur. This includes identification/analysis of secluded areas of the facility, sufficient staff to meet/anticipate the needs of the residents, assigned staff demonstrating knowledge of individual resident/ patient needs, sufficient and appropriate supervisory staff to identify inappropriate behaviors, and residents/patients with needs and behaviors which might lead to conflict or neglect.Resident #1 had diagnoses of unspecified dementia with mood disturbance (brain-related memory loss and thinking decline) major depressive disorder (an on-going sadness or loss of interest) and need for assistance with personal care (hands-on supportive care with daily tasks). The 02/20/2026 Minimum Data Set (a resident assessment tool) documented the resident had severely impaired cognition, required supervision/touch assistance for bathing, was independent with toileting hygiene and personal hygiene and was independently mobile. The Comprehensive Care Plan initiated 05/23/2025 documented Resident #1 required assistance with self-care and mobility related to confusion and dementia and had limited physical mobility related to dementia. Interventions included: encourage resident to participate to the fullest extent possible with each interaction; encourage use of call bell for assistance; and the resident walked independently.The 05/03/2026 facility investigation conclusion documented Resident #1 visited Resident #4 on Unit A South at 2:00 AM. Licensed Practical Nurse #8 misidentified Resident #1 as a visitor, asked them to leave and escorted the resident to the side employee door and out of the facility. Resident #1 was not discovered missing until 7:00 AM. A Code Grey (missing resident code) was initiated, and a facility wide search was completed and 911 was phoned. Resident #1 was found 1 mile away at a festival and upon return to the facility, had a quarter-sized abrasion to their scalp and a cut to their fingers. The resident was sent to the hospital per family request to be evaluated. The 05/3/2026 police report documented they received a 7:24 AM dispatch to the facility for a missing person. Upon arrival to the facility, Licensed Practical Nurse #17 informed them Resident #1 was discovered missing at 7:00AM and they phoned 911. The responding police officer conducted additional employee interviews, and it was determined that Resident #1 was escorted from the building at 2:00 AM by Licensed Practical Nurse #8. The police officer conducted a search of the community and was advised around approximately 11:00 AM, Resident #1 was returned to the facility.The 05/03/2026 at 11:05 AM nursing progress note by Registered Nurse #6 documented the resident was assessed upon return to the facility, had an abrasion to their right ring finger and an abrasion to the top of their scalp. Family was at the bedside and requested the resident be sent to the Emergency Department for evaluation.The 05/03/2026 at 7:36 PM hospital after visit summary documented Resident #1 was treated for a fall with head injury. The plan of care was to return to the emergency department if symptoms worsened.The 05/03/2026 at 8:20 PM nursing admission progress note by Licensed Practical Nurse Unit Manager #23 documented Resident #1 returned from the emergency department with no new orders and had a wound on the top of their scalp that measured 4.5 centimeters long by 0.5 centimeters wide.The 05/08/2026 at 6:09 AM Physician #14 progress note documented Resident #1 was seen for an elopement evaluation. Resident #1 could state their name and place but could not recall the time or year, had left the facility and was found downtown at a festival. The resident had a wound to their head with missing skin and hair on their scalp and stated they were hit in the head with a bamboo stick by a [NAME] artist and did not engage them. Physician #14's assessment and plan were to increase monitoring for exit- seeking behaviors, notify the family representative of event, cleanse and apply topical wound care to the resident's head and monitor for signs and symptoms of infection.On 07/13/2026 at 10:00AM, Resident #1 was observed laying on their bed. Resident #1 could not recall the events of the incident on 05/03/2026. They stated they remembered walking up the street and had to go check on someone. Resident #1 stated they saw the police and trusted them, and someone told them they had to return to the facility.During an interview on 07/13/2026 at 2:56 PM, Resident #1's family representative stated they received a call to inform them their relative was missing. They made a post on social media to assist others in helping to locate the resident. The family representative called the facility to inquire what happened and was told by an unnamed staff member that the resident was escorted outside by a staff member and 911 was called.During an interview on 07/13/2026 at 3:25 PM, former employee (Registered Nurse #15) stated they observed Resident #1 having an altercation with police approximately 2.6 miles away from the facility and informed police the resident was missing from the facility. Registered Nurse #15 stated the resident was cold, hungry, was incontinent of bowel and bladder and disoriented. They escorted the resident back to the facility and brought them in the front door into the lobby. The Administrator, Registered Nurse #2 and two unnamed supervisors were present upon the return.During an interview on 07/13/2026 at 4:10 PM, Licensed Practical Nurse #8 stated they observed Resident #1 in Resident #4's room at 2:00 AM. They assumed Resident #1 was a visitor, looked in the computer [electronic medical record program] twice to identify them and their search did not reveal the resident. They informed Resident #1 that visiting hours were over and escorted them to the first-floor employee exit door on the side of the building.During an interview on 07/14/2026 at 11:03 AM, Certified Nurse Aide #7 stated they worked on 05/03/2026 during the 11:00 PM to 7:00 AM shift on Unit A South. At 11:10 PM, they observed Resident #1 in Resident #4's room and were unfamiliar with them so they alerted Licensed Practical Nurse #8. During their second rounds at 2:00 AM, Resident #1 continued to be in Resident #4's room and they alerted Licensed Practical Nurse #8 again. Certified Nurse Aide #5 was present and told Licensed Practical Nurse #8 they thought the person was a resident but was not sure what unit they were from. Certified Nurse Aide #7 suggested they notify the supervisor and Licensed Practical Nurse #8 did not want to call them, as there was only one supervisor on duty. They stated Licensed Practical Nurse #8 looked up the resident in the computer and said they thought they were from a nearby in-patient substance use treatment facility. The nurse went into the room and then Resident #1 came out into the hall. Resident #1 appeared confused and did not know where to go. Certified Nurse Aide #7 stated they did not call anyone or say anything else due to observing the resident get on the elevator with Licensed Practical Nurse #8. They thought the nurse was returning the resident to their unit.During an interview on 07/14/2026 at 11:26 AM, Certified Nurse Aide #4 stated they worked the 11:00 PM to 7:00 AM shift on Unit C North. They were assigned to Resident #1, observed the resident on the Unit A South upon entering the facility and knew they were on another unit. Resident #1 always went to that unit and it was not unusual for the resident to be away from their room at night. The resident usually sat down at the C North Unit nursing station. Certified Nurse Aide #4 stated during their last round at 5:00 AM, they thought Resident #1 was in bed because their room privacy curtain was pulled but they did not enter the room.During an interview on 07/14/2026 at 2:24 PM, Certified Nurse Aide #5 stated they worked on Unit A South on 05/02/2026 from 3:00 PM to 11:00 PM, and then 05/03/2026 on the 11:00PM to 7:00 AM shift and observed Resident #1 on the unit since 3:00 PM. They informed Licensed Practical Nurse #8 the person in with Resident #4 was a resident, but they were unsure what floor they lived on. They assumed the nurse called other units to find out where the resident lived. Certified Nurse Aide #5 was not aware Resident #1 went missing until the morning at the end of the night shift, Licensed Practical Nurse #8 made a comment they escorted the resident out of the building around 2:00 AM.During an interview with the Administrator on 07/15/2026 at 11:30 AM, they stated if a resident leaves the building, they sign out at the front desk. Residents are identified by identification bracelets worn on their wrists, provided upon admission. If they prefer not to wear one, it could be a problem and documented in the electronic medical record. The facility's procedure for identification of residents includes asking their name, looking in the electronic medical record, looking at identification bracelets, asking a colleague, or looking up their picture. If an identification bracelet is missing or illegible, staff would have a conversation with the person and speak to colleagues to identify them. When Resident #1 was escorted out of the building, the Administrator was unsure if they had an identification bracelet at the time. The incident occurred due to the failure of Licensed Practical Nurse #8 to follow facility processes. Staff were expected to complete rounds every 2 to 4 hours and know they can communicate with other staff on other units if needed.During a follow up interview on 07/17/2026 at 10:30 AM, the Administrator stated they did not recall the statement from formerly employed Certified Nurse Aide #4, which included the aide did not enter Resident #1's room to observe them during the night or that Certified Nurse Aide #5 informed License Practical Nurse #8 that Resident #1 was a resident from another unit.10 NYCRR 415.4 (b)

Based on record review and interviews (#2994892) the facility failed to ensure intravenous fluids (fluids that were administered directly into a vein) were administered consistent with professional standards of practice and in accordance with physician orders. This was identified for one (1) of two (2) residents (Resident #1), reviewed for hydration and receiving intravenous therapy. Specifically, Resident #1 had an order for fluids via intravenous route, the fluids were not provided as ordered, and the resident received 1000 cubic centimeters all at once, instead of over time. Nursing staff did not monitor the rate of the fluid infusion. The physician telephone order was not transcribed as an order and was not included on the Medication Administration Record and was not documented as administered. A facility investigation was completed on whether the correct fluid was administered but did not address these concerns.Findings include:The facility's Intravenous Infusion Therapy policy, last reviewed April 2026, documented the physician's order for intravenous therapy must be verified with the medication bag/bottle. Nursing staff were to document medication, flushing agent, date, time, and the nurse administering on the medication administration record. The date, time, and resident response was to be documented on the appropriate nursing documentation. Resident #1 had diagnoses of hemiplegia (one sided weakness) affecting right dominant side following a cerebral infarction (stroke), dementia, and hypertension (high blood pressure). The 04/20/2026 Minimum Data Set assessment documented Resident #1 had intact cognition. The resident received antipsychotic, anti-anxiety, antidepressant, anticoagulant (prevents blood clots), diuretic and hypoglycemic (such as insulin) medications daily.The 11/16/2022 Comprehensive Care Plan Report documented the resident had actual/potential fluid deficient due to diuretic use (medications used to eliminate excess salt and water from the body). Interventions included monitoring laboratory results and medications as ordered by the physician, promoting additional fluid intake, monitoring vital signs, and reporting abnormalities.The 04/22/2026 general progress note by Primary Physician #10 documented Resident #1 was seen for increased somnolence (drowsiness) and unsteady gait. Their blood sugars were running higher, and the resident had been exhibiting signs of increased anxiety and depression. At that time, psychotropic medications were being cross tapered (switching one medication to another). The physician was to have the nurse manager order a complete blood count (blood test) and urinalysis to rule out infection and to monitor the resident's blood sugars. There were no other documented medical provider or nursing progress notes from 04/22/2026 through 04/25/2026 related to the resident's change in condition or orders for intravenous fluids. The 04/26/2026 at 12:12 AM nursing assessment progress note entered by Registered Nurse Supervisor #5 documented the following: 24 gauge (needle size) intravenous started to the resident's left forearm with immediate blood return and no discomfort. Normal saline 500 cubic centimeters bolus was initiated, after which the rate will be decreased to 100 cubic centimeters an hour for two days. The resident also received Rocephin (antibiotic) 1 gram intermuscular (injection into the muscle tissue) and then intravenous for seven days, with blood work, urinalysis and chest x-ray to follow. The 04/01/2026 through 04/26/2026 Order Summery Report did not contain the order for the intravenous therapy infusion of normal saline that was administered to the resident on 04/26/2026.The April 2026 Medication and Treatment Administration Records did not include the intravenous therapy infusion of normal saline.The 04/26/2026 facility internal investigation completed by the Administrator was initiated due to an accusation made by Registered Nurse Supervisor #6 that Registered Nurse Supervisor #5 administrated the wrong infusion of dextrose solution (sugar and water) instead of the normal saline to Resident #1. The investigation concluded this accusation was unfounded, and the resident received the correct intravenous infusion. A picture of the intravenous bag was obtained with a label that stated one liter of normal saline fluid was hung on 04/25/2026 at 10:50 PM, 500 cubic centimeters bolus then decrease rate. Statements included Registered Nurse Supervisor #6, who documented it was their mistake they read the bag wrong. Resident #1 was unresponsive and received the entire bag of intravenous fluid, as the bag and tubing were empty. The order was for 500 cubic centimeters bolus and not the entire bag. Registered Nurse Supervisor #5 did not stay with the resident to watch the amount of fluid given. The tubing was left wide open (tubing not clamped to adjust the flow rate, allowing for fluid for flow as fast as gravity and the size of the catheter allow) and the bag emptied.The 04/26/2026 facility investigation did not address the error in the intravenous infusion, or the lack of documentation and physician orders. During an interview on 05/11/2026 at 12:30 PM the Administrator stated the Director of Nursing was out on extended sick leave and a nurse consultant was filling in, although the nurse consultant was not involved in the investigation on 04/26/2026. The Administrator stated due to not being a nurse, they did not address the errors with the administration of the intravenous fluid including: infusing all at once instead of the 500 cubic centimeters bolus and then 100 cubic centimeters an hour; the telephone order not transcribed and not placed in the Medication Administration Record as given; and the empty intravenous bag still attached to the resident with the tubing open.During a phone interview on 05/12/2026 at 12:13 PM Registered Nurse Supervisor #5 stated on 04/26/2026 they were mainly concerned about the accusation Registered Nurse Supervisor #6 made that they gave Resident #1 dextrose instead of normal saline. After initiating the intravenous therapy, they went back to the supervisor's office because it was change of shift. They told Licensed Practical Nurse #8 to monitor the infusion because they left the tubing wide open and when the fluid went down to 500 cubic centimeters, the drip needed to be turned down. This was also told to the oncoming nurse, Registered Nurse Supervisor #6, plus the instructions were on the bag. Registered Nurse Supervisor #6 left and then returned to the supervisor's office upset. They did not speak about all the fluid being infused at once. They were concerned about the possibility of dextrose being given instead of the normal saline. During a phone interview on 05/12/2026 at 12:36 PM, Licensed Practical Nurse #8 stated they worked the 3:00 PM to 11:00 PM shift on 04/25/2026. A certified nursing assistant came to them and said that Resident #1 was in bed and did not appear well. Registered Nurse Supervisor #5 was notified, called the on-call medical provider, and obtained an order to start intravenous therapy. The licensed practical nurse and the certified nursing assistant sat with the resident, and they were still there after midnight. A licensed practical nurse can monitor the infusion site for any reaction, but a registered nurse starts the infusion and adjusts the drop flow (rate). Licensed Practical Nurse #8 did not touch the bag or tubing and told the oncoming nurse, Licensed Practical Nurse #12 about the resident.During a phone interview on 05/12/2026 at 1:23 PM Registered Nurse Supervisor #6 stated (on 04/26/2026, when they accused Registered Nurse Supervisor #5 of using the wrong fluid) they misread the bag as dextrose, and apologized for their error. They were told by Registered Nurse Supervisor #5 the infusion was to run as a 500 cubic centimeters bolus and then 100 cubic centimeters every hour. The fluid bag started at approximately11:00 PM, and Registered Nurse Supervisor #5 did not stay and monitor it because they were busy with other residents who had falls. During a phone interview on 05/12/2026 at 4:41 PM Certified Nursing Assistant #9 stated on the evening shift of 04/25/2026, they asked Registered Nurse Supervisor #5 to look at the resident who was sweating. The resident's blood sugar was high and an intravenous line was placed in their arm. Their shift was over (at 11:00 PM), but they stayed in the resident's room. There was fluid left in the bag and the resident was lying there sleeping. During a phone interview on 05/12/2026 at 5:05 PM Licensed Practical Nurse #12 stated they worked the11:00 PM to 7:00 AM shift on 04/26/2026. They thought the infusion had started around 10:30 PM and around the same time, the resident's blood sugar was still high. After report they went to the resident's room, looked at the resident's intravenous site, and there was a small amount of fluid left in the bag.10 New York Codes, Rules and Regulations 415.12(k)(2)

Based on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in one (1) of one (1) main kitchen. Specifically, the main kitchen walk-in freezer had ice built up on the floor and the compressor was leaking. Findings include:The facility policy Food Storage, revised 05/2024, documented all freezer units would be kept clean and in good working condition. Freezer temperatures should be checked at least two times each day and proper unit functioning would be checked at each temperature check. The facility policy Equipment Failure and Repair, revised 03/2022, documented staff was trained to report equipment that did not work or was not functioning properly to maintenance. Outside repair service would be called if problem could not be corrected in a reasonable time frame by facility maintenance staff.The 04/29/2026 vendor Duffy's AIS invoice stated the walk-in freezer was serviced on 04/28/2026 for extensive ice built up on the floor under the condenser. The unit was working properly, and the door gasket was in good repair.During an observation on 04/27/2026 at 09:25 AM, extensive ice was built up under the condenser and icicles were hanging off the compressor. The ice caused the shelving to be moved out a few feet from the wall. The reach in freezer and refrigerator number 1 (one) had ice built up in the back of the refrigerator near the condenser. Food Service Director #14 stated the freezer was just fixed recently and they were waiting until they were sure the problem was resolved before they cleaned up the ice. The refrigerator was likely opened recently and they would monitor it. During an observation and interview on 04/27/2026 at 1:44 PM, the floor beneath the compressor in the walk-in freezer was covered with icy build-up, several inches thick. Food product was moved from the area, but ice had spread almost a quarter of the total area of the freezer. Maintenance Director #17 stated the vendor Duffy's AIS was in the facility a week or two ago and thought the issue was resolved. During an observation and interview on 04/29/2026 at 11:30 AM, the freezer still had some ice and debris on the floor, and a small icicle was present on the drain line with some lines of ice on the back wall. The Administrator was present and stated they thought the problem had been fixed a week or two ago. There was iced observed around the wall and the Administrator had to close the door twice during the kitchen visit, after staff left the door slightly ajar.During an observation on 04/30/26 at 12:00 PM, the walk-in freezer had ice building up again and appeared to come from in front of the compressors and dripped from the ceiling. An icicle was noted on the drain line and ice on the back wall.During an observation on 05/01/2026 at 2:30 PM, most of the ice was gone from the floor, but icicles were noted hanging under the compressor. The gasket on the door appeared torn and part of it was hanging sideways.10 New York Codes, Rules, and Regulations 415.5(e)(1)(2)

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety and did not follow proper sanitation practices to prevent the outbreak of food borne illness in one (1) of one (1) main kitchen and one (1) unit refrigerator (D South). Specifically, ten pans of prepared or leftover food in walk in coolers were not labelled; ten pans of fish were prepared and not labelled or dated; the dish machine wash temperature did not reach the required temperature; the dish machine sanitizer concentration was not monitored; Assistant Administrator #16 was in the main kitchen without a beard cover; there was debris and dried food built up on the floor and along the walls in the coolers and production areas; the reach in cooler gaskets had built up dried residue; and the unit refrigerator on D South had a dried sticky substance.Findings include:The facility policy Food Storage, revised 05/2024, documented all food would be clearly labeled and dated to assure that foods (including leftovers) would be consumed by their safe use by dates. All refrigerator units would be kept clean and in good working condition.Food StorageDuring an observation and interview on 04/27/2026 at 9:25 AM, the produce walk-in cooler in the main kitchen contained several unlabeled containers of prepared or leftover food dated 04/26, identified by the Food Service Director as fortified pudding, egg salad, plain tuna, tuna salad, pureed tuna, and apples. A partially covered pan of dessert was not labeled or dated and identified as cake. The Food Service Director stated the food should be labeled to prevent staff from serving the wrong item. During an observation on 04/27/2026 at 9:40 AM, walk-in cooler Number 2 had unlabeled containers of prepared or leftover food dated 04/26 identified by the Food Service Director as chicken, cucumber tomato salad, and pasta salad.During an observation on 04/27/2026 at 9:48 AM, the meat walk-in cooler contained ten pans of fish prepared the previous day. The Food Service Director stated the pans should be labeled and dated on the plastic cover. It should be labeled and dated so staff knew when it went into the cooler and what the item was.SanitationThe 02/25/2026 Emergency Service Report documented the dish machine final rinse did not reach the required 180 degrees Fahrenheit, and the dish machine was converted to a low temperature chemical sanitizing machine. The wash temperature was 128 degrees Fahrenheit, and the sanitizer concentration was 50 to 100 parts per million on several tests. The Food Service Director and Maintenance Director were notified of the change, and the Food Service director received an e-mail with the report.The 02/26/2026 through 04/08/2026 and 04/19/2026 through 04/26/2026 dish machine temperature logs, documented the wash temperature was exactly 150 degrees Fahrenheit and the final rinse was 180 degrees Fahrenheit (the requirement of a high temperature dish machine). There was no documented evidence the sanitizer strength was tested between the vendor testing on 02/25/2026 and 04/29/2026. The Low Dish Machine Temperature Log, initiated 04/29/2026 at 10:30 AM with the surveyor present, documented the dish machine wash temperature was 110 degrees Fahrenheit on 04/28/2026 midday. The vendor invoice dated 04/23/2026, documented the dish machine was serviced on 04/02/2026 and noted the temperature gauges did not work correctly. The repair was completed on 04/23/2026 and did not document any changes to the machine from high temperature to low temperature.During an observation and interview on 04/29/2026 at 10:15 AM, the dish machine wash temperature was 110 degrees Fahrenheit (minimum requirement is 120 degrees Fahrenheit) and was verified by the Food Service Director who stated they would call maintenance. They did not think it was an issue to use the machine if it did not reach the required wash temperature if the dishes were sanitized properly. They stated they thought the machine was out of service a week ago, around 04/12/2026, was converted from a high temperature machine to a low temperature chemical sanitizing machine and was tested on ce a day for a temperature check by whoever was running the dish machine that day.The April 2026 Dish Machine Temperature Log documented the following:-the dish machine temperature was to be tested three (3) times a day, once at each meal;- the required temperature for the wash cycle was 150 degrees Fahrenheit, and the final rinse was 180 degrees Fahrenheit;-entries were missing for the dinner meal on 04/08/2026, 04/09/2026, 04/10/2026, and 04/11/2026;-no temperatures were taken from 04/12/2026 through 04/18/2026;-the temperatures recorded on 04/19/2026 through 04/26/2026 were for a high temperature sanitizing machine, instead of a chemical sanitizing machine-there was no place to document the sanitizer chemical strength, and no evidence the sanitizer strength was tested in the dish machine since the conversion to chemical sanitizing.During an interview and observation on 04/29/2026 at 10:15 AM, the Food Service Director stated they did not have documented evidence they tested the chemical concentration of the dish machine. They stated they just got the new form today and that was why it was not in use yet. They did not know why the form in use was still documenting as a high temperature machine. They tested the sanitizer strength at 10:33 AM in the dish machine and it was in acceptable range to properly sanitize. They stated Food Service Worker #15 was responsible for documenting the dish machine temperatures on weekdays and a supervisor was supposed to test the sanitizer strength.During an interview on 04/29/2026 at 10:40 AM, Food Service Worker #15 stated they rotated positions in the kitchen and usually recorded the breakfast and lunch dish machine temperatures. The wash temperature should be 180 degrees Fahrenheit, and the sanitizing should be 170 degrees Fahrenheit. The facility just added chemicals to sanitize last week, and they did not know if that changed the required temperature readings. They stated they sanitized dishes to kill bacteria.During an observation and interview on 04/29/2026 from 11:00 AM through 11:30 AM, Assistant Administrator #16 was in the kitchen on the production floor and was not wearing a beard net to cover their full beard. The Food Service Director stated any staff, including vendors, were required to wear hair restraints and cover beards with a beard restraint anytime they entered any area of the kitchen.Equipment Safe/Clean:During an observation and interview on 04/27/2026 at 9:25 AM, the main kitchen had debris and dried food build up on the floor and along the walls in the production areas near the cook, the tray line, and dish washing areas. The reach in cooler gaskets had built up dried residue in them. The Food Service Director stated staff cleaned the kitchen daily but there were no formal cleaning schedules and staffing had been a struggle lately. Those areas should be cleaned daily to prevent bacteria growth.During an observation on 04/27/2026 at 11:30 AM, the refrigerator in the pantry on unit D South had a dried, and sticky substance built up on the bottom.During an interview on 05/01/2026 at 2:28 PM, the Food Service Director stated Administrative Assistant #16 knew they required a beard net because they had been told about that before. The unit refrigerators should be cleaned daily by dietary aides. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews (IQIES 2984903), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for five (5) of seven (7) residents (Residents #4, # 8, #13, #100, and #209) reviewed. Specifically: - Resident #8 had multiple pressure ulcers including a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum (lower back between the hip bones) that were not routinely assessed (determining stage, size and wound characteristics, appropriateness of treatment) by a qualified individual; newly identified pressure ulcers were not assessed by a qualified individual; pressure ulcer status was determined by a non-qualified individual and the wound evaluations were inconsistent and either included pressure ulcers not previously documented or did not include pressure ulcers that were previously identified. -Resident #209's pressure ulcers were not assessed by a qualified individual upon readmission to the facility and care plan interventions and wound treatments were not completed as ordered. -Resident #4's pressure ulcers were not assessed by a qualified individual, and the treatment was not /completed as ordered. -Residents #12's and #100's pressure ulcers were not assessed by a qualified individual.This resulted in Substandard Quality of Care for residents with pressure ulcers.Findings include: The New York State Education Department, Consumer Information for Licensed Practical Nurses documents, New York State law does not allow licensed practical nurses to: practice nursing independently, perform nursing assessments or triage, or develop nursing care plans. Licensed practical nurses are not allowed to provide clinical services that require nursing or medical assessments. The facility policy Skin and Pressure Injury Prevention, revised 06/27/2024, documented the facility will assess residents for risk in development of pressure injuries and implement preventative measures in accordance with current standards of practice. The Risk Assessment included assessment of the resident's skin on admission/readmission for existing pressure/injury risk factors utilizing the Braden Risk Assessment, a comprehensive skin assessment upon admission/readmission, weekly skin monitoring by the licensed nurse and staff to inspect the skin when performing personal care. The facility policy Wound Identification and Wound Rounds, revised 11/06/2023, documented the facility will identify, assess, and manage residents with pressure injuries in accordance with current standards of practice. For a newly identified pressure injury the registered nurse completes a skin assessment including documentation of size, depth, stage if applicable, licensed nurse will obtain treatment order and the Wound Nurse/Designee are notified and resident scheduled for weekly wound rounds. For a new wound identified in-house the licensed nurse will perform weekly and as needed skin monitoring and describe their findings in the Electronic Medical Record. The licensed nurse will notify the registered nurse who will complete an Initial Wound Assessment including shape, size, depth, staging and peri-wound. The resident is scheduled for weekly wound rounds. Any wound identified as worsening defined by increase in pain, drainage, necrotic tissue or odor will be assessed by a registered nurse. 1)Resident #8 had diagnoses including stroke, diabetes, and a Stage 4 pressure ulcer on the sacrum. The 04/20/2026, Minimum Data Set (resident assessment) documented the resident had severely impaired cognition; was dependent for most activities of daily living including toileting and bed mobility; was at risk for pressure ulcer development; had a Stage 4 unhealed pressure ulcer; skin and pressure ulcer treatments included pressure reducing device for chair and bed, nutritional/hydration intervention, pressure ulcer care and application of ointments/medications. The 03/28/2026, comprehensive care plan documented the resident was at risk for pressure ulcer development and had actual pressure injury as evidence by Stage 4 on the sacrum, one Stage 3 (full thickness tissue loss) and two (2) unstageable (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) pressure ulcers on the left foot, one unstageable on the right foot, and one unstageable on the left lower leg. Interventions included apply treatment per order, monitor/document report to physician any changes in skin and refer to wound care specialist as needed, turn and reposition every 2-3 hours as indicated, offload heels with pillows and air mattress. The 03/25/2026 readmission Evaluation completed by Registered Nurse #71 documented the resident had the following skin alterations: -Unstageable to the right toe (which toe not identified) measuring 1.8 centimeters x 0.4 centimeters with 100% eschar (black/brownish dead tissue) to the wound bed. -Unstageable to the left toe (which toe not identified) measuring1.3 centimeters x 1.0 with 100% eschar to the wound bed. -Unstageable to the right outer foot measuring 2.3 centimeters x 0.5 centimeters with the wound bed containing 10% granulation tissue (healing tissue) and 90% slough (yellow/whitish dead tissue). -Unstageable to left inner foot measuring 1.8 x 0.8 centimeters, with 100% eschar to the wound bed. -Unstageable to outer left foot measuring 2.8 centimeters x 1.4 centimeters, with 100% eschar to the wound bed. -Unstageable to the left heel, measuring 1.5 centimeters x 1.5 centimeters, with 100% eschar to the wound bed. -Unstageable on the left heel, measuring 1.0 centimeters by 1.0 centimeters and 100% eschar. -Stage 4 pressure ulcer on the sacrum measuring 13.0 centimeters x 20.0 centimeters (no depth documented). The wound had tunnelled (passageways beneath the skin, extending into deeper tissues like muscle or fat) and undermining (a pocket beneath the visible wound margin) had slough granulation yellow green exudate unable to visualize wound bed. On 04/01/2026, Licensed Practical Nurse #11 completed a Weekly Wound Evaluation and the documented the following: -Unstageable pressure ulcer to the [NAME] outer foot measuring 1.4 centimeters x 1.5 centimeters x 0.1 centimeters. The wound bed contained 100% slough. -Unstageable pressure ulcer left inner foot measuring 1.0 centimeter x 0.7 centimeters x 0.1 centimeters. The wound bed contained 100% slough. -Unstageable pressure ulcer to the left outer foot, measuring 0.9 centimeters x 0.5 centimeters x 0.1 centimeters and the wound bed contained 100% slough. -Suspected Deep Tissue Injury (purple/maroon area due to damage of underlying tissue) on the left heel measuring 1.0 centimeter x 0.7 centimeter. -Unstageable pressure ulcer to left inner distal foot, measuring 1.0 centimeter x 1.0 centimeter x 0.1 centimeters. The wound bed contained 100% slough. -Unstageable pressure ulcer to the right inner foot was closed-remains fragile and under observation. -Stage 4 pressure ulcer on the sacrum measuring 10.0 centimeters x 17.0 centimeters x 2.9 centimeters and undermining 2.5 centimeters at 12 o'clock. The wound bed was 50% granulation tissue, 25% slough and 5% eschar. Additional comments included 15% muscle fascia (connective tissue encasing muscle) and 5% bone. The pressure ulcer had improved. There was no documented evidence that the pressure ulcers documented by Licensed Practical Nurse #11 were assessed by a qualified person. There was no evidence of any follow up regarding the pressure ulcer areas noted on the resident's right and left toes, and the two pressure ulcers on the left heel noted by Registered Nurse #71 on 03/25/2026. There was no documented evidence the additional pressure ulcers documented on the resident's right and left inner feet and the suspected deep tissue injury on the left heel were assessed by a qualified person. The 04/06/2026, Physician Assistant #72 progress note documented during physical exam the resident's skin did not have any rashes or lesions noted. On 04/08/2026, Licensed Practical Nurse #10 completed a Weekly Wound Evaluation and documented the following: -Unstageable pressure ulcer on the right outer foot, measuring 1.8 centimeters x 1.0 centimeters x 0.1 centimeters. The wound bed contained 90% granulation tissue and 10% slough. -Unstageable pressure ulcer on the left inner foot measuring 0.8 centimeters x 0.8 centimeters x 0.1 centimeters. The wound bed contained 90% granulation tissue and 10% slough. -Unstageable pressure ulcer left outer foot measuring 0.3 centimeters x 0.3 centimeters x 0.1 centimeters. The wound bed contained 100% slough. -Suspected deep tissue injury on the left heel and the wound status was healed/resolved. -Stage 4 pressure ulcer on the sacrum measuring 10.0 centimeters x 18.0 centimeters x 1.2 centimeters and undermining 2.2 centimeters at 12 o'clock. The wound bed contained 50% granulation tissue, 25% slough, and 5% eschar. -Unstageable pressure ulcer left outer foot measuring 0.3 centimeters x 0.3 centimeters x 0.1 centimeters. The wound bed contained 100% slough. -Unstageable pressure ulcer left inner distal foot measuring 1.5 centimeters x 2.0 centimeters x 0.1 centimeters. The wound bed contained 80 % granulation tissue, 20% slough. There was no documented evidence the pressure ulcers documented by Licensed Practical Nurse #10 were assessed by a qualified person. During an interview on 04/29/2026 at 12:50 PM, Licensed Practical Nurse #11 stated often when they completed dressing changes, dressings were not changed as ordered. Dressing changes were ordered to promote healing of the wound and when treatments were not completed as ordered, wound healing could be impacted. During an interview on 04/30/2026 at 11:43 AM, Licensed Practical Nurse #11 stated they did not complete wound assessments, only evaluated the wounds by collecting data. They documented if the wound was stable or improving, however when the wound was declining, they notified a registered nurse. Most residents were seen weekly by a wound care physician; however, the facility was without a wound physician for about six weeks. They expected the new wound care physician to start this week. During a wound care observation and interview on 05/01/2026 at 12:02 PM, Wound Care Physician #38 stated they assessed and monitored wounds weekly and made recommendations based on their assessment. When they were not in the facility, the nurse assigned to the resident was responsible for completing wound treatment as ordered. During an interview on 05/01/2026 at 11:09 AM, Licensed Practical Nurse #11 stated they completed Resident #8's Braden assessment on 04/09/2026, and the resident was at a high risk with a score of 12. The resident was admitted with multiple extensive pressure wounds. When they noticed the wounds getting worse or if they appeared infected, they would have the nurse practitioner, or a registered nurse assess the wounds right away. 2) Resident #209 had diagnoses including multiple sclerosis (progressive neurological disease) and infection of the left heel pressure ulcer. The 04/01/2026 Minimum Data Set documented the resident had intact cognition, required moderate assistance for personal care and bed mobility, had a chronic urinary drainage tube and was frequently incontinent of stool. The resident was at risk for pressure ulcer development; had Stage 3 and Stage 4 unhealed pressure ulcers; skin and pressure ulcer treatments included pressure reducing devices for chair and bed, turning/repositioning program, nutritional/hydration intervention, and pressure ulcer care. The 10/22/2025, comprehensive care plan documented the resident was at risk for and had alteration in skin integrity as evidence by a Stage 3 on the left heel and Stage 4 on the left inner ankle. Interventions included, off load heels with pillow or boots as tolerated, weekly assessment of wound by licensed nurse or provider, including length, width, depth, tissue type, drainage, odor, pain and signs/symptoms of infection. On 01/05/2026, the care plan was updated to include apply treatment per order, avoid clothing/devices/footwear that may impede healing and communicate status of wound to resident or representative. The 04/20/20206, Admission/readmission Evaluation Part One completed by Licensed Practical Nurse Unit Manager #5 documented the resident had a pressure injury on the left outer ankle. There was no further description of the wound or additional skin impairments noted. On 04/21/2026, a Weekly Wound Evaluation completed by Licensed Practical Nurse #11 documented the following: -The resident was not seen by the wound care provider. -Stage 3 pressure ulcer on the left heel, measuring 0.8 centimeters x 1.0 centimeters and the description of the wound was dry scab. -Stage 4 pressure ulcer on the left inner ankle, measuring 5.0 centimeters x 5.5 centimeters x 0.1 centimeters and the wound bed contained 100% granulation tissue. There was no documented evidence the pressure ulcers were assessed by a qualified person and there was no documentation related to the pressure ulcer noted on the left outer ankle by Licensed Practical Nurse Unit Manager #5 on 04/20/2026. The 04/21/2026, physician orders included cleanser left inner ankle with wound cleanser, apply collagen and alginate AG to wound bed and cover with absorbent pad, every evening shift and as needed if dressing was soiled or displaced. Cleanse left heel with wound cleanser and leave open to air every evening. During an observation and interview on 04/27/2026 at 9:32 AM, Resident #209 was in bed with their left heel resting directly on the mattress. The left inner ankle had a dressing dated 04/25/2026. Resident #209 stated their dressing was last changed on 04/25/2026 at approximately 4:30 PM by Licensed Practical Nurse #12 who also worked 04/26/2026 on the evening and overnight shift. They asked Licensed Practical Nurse #12 if they could change the dressing and they said they were too busy to change the dressing. The April Medication Administration Record documented the treatment to the resident's left inner ankle was completed on the evening shift of 04/25/2026 and 04/26/2027 by Licensed Practical Nurse #12. During an interview on 4/30/2026 at 11:43 AM, Licensed Practical Nurse #11 stated they would not assess the resident's wound. They collected the data if the wound was stable or improving. If the wound was declining, they must inform the registered nurse on the wound team or whatever registered nurse they could find to assess the wound. They stated the facility had not had a wound physician for six weeks. During an interview on 04/30/2026 at 2:40 PM, Licensed Practical Nurse #12 stated most dressing changes were done on the day shift, by the wound team, but if the wound team did not do the dressing, they completed the dressing change. They signed off on all their resident dressing and treatments at the beginning of their shift, and if a resident refused the treatment they went back in the record and documented an addendum progress note. They stated they may have put the wrong date on the resident's dressing on 04/26/2026. The resident was alert and oriented and if they said the dressing was not done, then it was not done. They stated sometimes it was very busy, and they had to prioritize what needed to be done. During a follow-up interview on 05/01/2026 at 11:09 AM, Licensed Practical Nurse #11 stated Resident #209's last Braden assessment was completed on 03/01/2026 and the resident was considered a moderate risk meaning the resident was still at risk and predisposed to pressure ulcers. 3) Resident #4 had diagnoses including venous insufficiency (poor circulation), lymphedema (fluid buildup), and muscle weakness. The 04/01/2026 Minimum Data Set documented the resident had intact cognition, was independent for most activities of daily living, was at risk of developing pressure ulcers, had Stage 2 and Stage 4 unhealed pressure ulcers, had pressure reducing devices for the chair and bed, was on a turning and repositioning program, had nutrition/hydration interventions, pressure ulcer care and application of nonsurgical dressings. The12/08/2024 comprehensive care plan documented the resident was at risk of developing pressure ulcers related to impaired mobility. Interventions included gel/foam cushion for wheelchair and offload heels with pillows or boots. On 02/01/2026, the comprehensive care plan was updated to reflect the resident had an actual Stage 4 pressure ulcer on the left heel and left outer shin. Interventions included to apply treatment per order and evaluate the wound weekly and as needed. The 03/11/2026, Wound Physician Consultation note documented the resident had a Stage 4 pressure ulcer on the left heel, measuring 2.5 centimeters x 2.0 centimeters x0.2 centimeters. The wound bed contained 90% granulation tissue and 10% slough. The resident also had a Stage 4 pressure ulcer to left outer shin, measuring 4.0 centimeters x 2.0 centimeters x 0.4 centimeters. The wound bed contained 70% granulation tissue and 30% slough with undermining of 0.5 centimeters at 1 o'clock. Both pressure ulcers were debrided to remove necrotic tissue and establish margins of viable tissue. There was no further documentation from the Wound Physician Consultant. The following Weekly Wound Observations were completed by a licensed practical nurse: -On 03/18/2026 the left heel Stage 4 measured 2.0 centimeters x 1.8 centimeters x 0.2 centimeters and the wound bed contained 90% granulation tissue and 10% slough. The left outer shin Stage 4 measured 3.7 centimeters x 1.8 centimeters x 0.3 centimeters and there was no description of the wound bed. There was no documentation related to the undermining noted by the Wound Physician on 03/11/2026. -On 03/25/2026 the left heel Stage 4 measured 0.8 centimeters X 0.8 centimeters and the wound bed contained 80% granulation tissue and 20% slough. The left outer shin Stage 4 measured 2.5 centimeters x 1.2 centimeters x 0.2 centimeters. The wound bed contained 40% new skin growth, 40% granulation tissue and 20% slough. -On 04/01/2026 the left heel Stage 4 measured 0.6 centimeters x 0.6 centimeters x 0.1 centimeters and the wound bed contained 90% granulation tissue and 10% slough. The left outer shin Stage 4 measured 2.8 centimeters x 1.0 centimeters x 0.2 centimeters and the wound bed contained 95% granulation tissue and 5% slough. -04/06/2026 the left heel Stage 4 measured 0.5 centimeters by 0.5 centimeters x 0.1 centimeters and the wound bed contained 90% granulation tissue and 10% slough. The left outer shin Stage 4 measured 2.5 centimeters x 1.2 centimeters x 0.1 centimeters and the wound bed contained 95% granulation tissue and 5% slough. -04/13/2026 the left heel Stage 4 measured 0.4 centimeters x 0.5 centimeters x 0.1 centimeters and the wound bed contained 95% granulation tissue and 5% slough. The left outer shin Stage 4 measured 2.6 centimeters x 1.5 centimeters x 0.1 centimeters and the wound bed contained 95% granulation tissue and 5% slough. -04/23/2026 the left heel Stage 4 measured 0.3 centimeters x 0.3 centimeters x 0.1 centimeters and the wound bed contained 100% granulation tissue. The left outer shin Stage 4 measured 2.2 centimeters x 1.8 centimeters x 0.1 centimeters and the wound bed contained 100% granulation tissue. There was no documented evidence from 03/11/2026-04/23/2026 the resident's pressure ulcer was assessed by a qualified individual. The April 2026 Treatment Administration Record documented the dressing to the resident's left outer shin was not done and Other/See Nurses Note. There was no documented evidence indicating why the dressing to the left outer shin was not changed on 04/28/2026. During an observation on 04/29/2026 at 5:44 AM the resident's left leg was resting on a pillow with a dressing dated 04/27/2026. During an observation and interview on 04/29/2026 at 12:50 PM Licensed Practical Nurse #11 stated the dressing had the date 04/27/2026, which indicated the dressing was not changed on 04/28/2026. It should have been changed as the resident never refused wound care. They stated that many times when they completed rounds with the wound care team, they found dressings were not being changed as ordered. Provider orders should be followed and the dressings done as they were ordered. During an interview on 04/30/2026 at 2:40 PM, Licensed Practical Nurse #12 stated they signed off they completed Resident #4's dressing but they did not complete it. They were unable to complete the dressing change to the wound because the resident was not in bed, and it was on the foot. They stated when the resident was in bed, they refused to have the dressing changed. They did not write a progress note or notify the supervisor. During an interview on 05/01/2026 at 11:09 AM, Licensed Practical Nurse #11 stated the resident's Braden score was a 12 on 03/07/2026 and meaning the resident was a high risk and predisposed to develop pressure injury. If a resident was high risk they would encourage repositions, elevate heels, and use lotions. As the licensed practical nurse, they did not initiate care plan goals/ or focus areas but would make recommendations for interventions. During an interview on 05/01/2026 at 12:23 PM, Licensed Practical Nurse #9 stated they were part of the wound team along with Licensed Practical Nurse #10 and Registered Nurse #13. They recently had a new wound care provider start. Occasionally a provider or registered nurse would sign off on their notes. If a wound was healing or resolved they updated a registered nurse, however, they were not always able to find a registered nurse. They probably should not have documented a wound as healed or resolved, as that was an assessment. The wound team rounded together and wrote down the measurements and assessments on paper then split up the residents and documented them in the electronic medical record. It was possible to document data that was completed by someone else. During an interview on 05/01/2026 at 1:19 PM, Licensed Practical Nurse #10 stated they documented that Resident #13's wound healed and resolved. They did not tell a registered nurse since the wound team registered nurse was not available. They should not have assessed and documented the wound as resolved; the registered nurse should have assessed the wound and resolved it. During an interview on 05/01/2026 at 1:46 PM, Assistant Director of Nursing #3 stated the Braden Risk Assessment was reviewed by registered nurses. The licensed practical nurse would start the Braden Risk Assessment, but a registered nurse finished the assessment and signed it. Licensed practical nurses should not document whether a wound was healed or resolved. The registered nurse needed to assess the wound and write a note. During an interview on 05/01/2026 at 2:06 PM, Registered Nurse #13 stated they were part of the wound team and had not received specific training on wounds. They performed and documented the initial wound assessments. They were unsure what a licensed practical nurse could document versus what was considered an assessment. The licensed practical nurse informed a registered nurse if the wound was worsening. A registered nurse or wound provider should assess the wound and document. During an interview on 05/05/2026 at 12:07 PM, the Administrator stated they had a wound team that consisted of Registered Nurse #13, Licensed Practical Nurse #9 and Licensed Practical Nurse #10. They did not know how often the wound team rounded. They did not know the scope of practice for licensed practical nurses or registered nurses. During a follow-up interview on 05/05/2026 at 12:25 PM, Nurse Consultant #69 stated licensed practical nurses were able to follow and evaluate the wound since an initial assessment was completed by a registered nurse and the registered nurse and provider accompanied them on wound rounds. There was a gap in time when there was no provider present in the facility during the evaluation. 10 New York Codes, Rules and Regulations 415.12(c)(1)

Based on observations and interviews the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards and principles for two (2) of twelve medication carts (Unit C North and Unit 3 medications carts) and one (1) of two (2) treatment carts (Unit C South) reviewed. Specifically, the Unit C North medication cart was unlocked and unattended and contained pre-poured medications, expired eye drops and inhalers, and unlabeled insulin; the Unit 3 South medication cart had open unlabeled lidocaine (anesthetic) and expired insulin pens; and the Unit C South treatment cart was unlocked and unattended and contained scissors, antifungal cream, and antiseptics.Findings included:The facility policy Medication Storage and Labeling, last reviewed 01/21/2026, documented medications were stored safely and securely in a locked cabinet, cart or medication room that was accessible only to licensed nursing staff. Expired medications were removed from the medication storage areas and disposed of in accordance with state and federal regulations. The facility did not use outdated drugs or biologicals. Compartments containing drugs and biologicals were locked when not in use, when unattended, or when potentially available to others.The facility policy Administering Medications, last reviewed 12/2029, documented when multi-dose medications were opened the date opened was recorded on the container, and during administration of medications, the medication cart was kept closed and locked when out of sight of the medication nurse. Medications may not be prepared in advance and must be administered within 1 hour of their prescribed time. The medication cart was to be kept closed and locked when out of sight of the medication nurse. Unit C North Medication Cart and Unit C South Treatment Cart:During an observation and interview on 04/27/2026 at 9:24 AM, the Unit C North medication cart was unlocked and unattended. There were pre-poured medications on the cart which included Eliquis (blood thinner), Myrbetriq (for overactive bladder), Vitamin D, carvedilol (antihypertensive), magnesium (mineral), duloxetine (antidepressant), an eye vitamin tablet, pantoprazole (for reflux), and metformin (used to treat diabetes). A resident was standing next to the medication cart. There were no staff in the area. Licensed Practical Nurse #25 stated they should not leave medication on the cart or leave the cart unlocked and unattended; they must have gotten distracted. They stated leaving the medication cart unlocked was a safety issue.During an observation on 04/27/2026 at 2:34 PM, the Unit C North medication cart was unlocked and unattended.During an observation and interview on 04/28/2026 at 1:57 PM, the first drawer of the Unit C North medication cart contained one (1) bottle of expired eye drops; the second drawer contained an expired Ventolin inhaler, an expired Advair disk inhaler, and one (1) unlabeled insulin bottle. Licensed Practical Nurse #53 stated when they noticed a medication was not labeled or expired, they threw it out because it was no longer any good.During an observation on 04/29/2026 at 11:52 AM the C South treatment cart was unlocked and unattended. The cart contained a pair of scissors, antifungal cream, and antiseptics.During an interview on 04/30/2026 at 9:37 AM, Licensed Practical Nurse #24 stated medication and treatment carts should always be locked. There were items kept in both carts that could pose risk to residents.During an interview on 04/30/2026 at 12:34 PM, Licensed Practical Nurse Unit Manager #5 stated the medication and treatment carts should be locked when unattended. Medications should never be left on the carts unattended, and medications should be labeled once opened. Treatment carts contained wound cleanser, scissors, medicated creams, hair and mouth wash. All items posed risk to residents. They stated when a vial of insulin was opened it should be labeled to keep track of when it expired. There were many medications that required labeling when first opened by the nurse. Unit 3 South Medication Cart:During an observation and interview on 04/28/2026 at 1:48 PM the top drawer of the Unit 3 South medication cart had an open, unlabeled bottle of lidocaine (anesthetic). Licensed Practical Nurse #66 stated the lidocaine was most likely a one-time dose from the electronic medication dispensing machine and they did not know when the bottle was opened. The second drawer contained two (2) expired insulin pens. Licensed Practical Nurse #66 stated both insulin pens were expired, and everyone was responsible for checking dates for expired medications. They stated they did not know why the pens or lidocaine bottle had not been removed.During an interview on 05/01/2026 at 10:24 AM, Assistant Director of Nursing #3 stated medication carts should be locked when unattended. They contained products that could cause harm to others. Insulins should be labeled after opening and carts should be organized. It was the responsibility of the licensed practical nurse that opened the medication to label the container. If insulin, eye drops, or inhalers were opened and the nurse did not see an open date on it, they should discard and reorder the items from pharmacy because they did not know what day it was opened. Treatment carts should always be locked. Many items in the carts could be dangerous to the residents. Medication and treatment carts should ever be left unattended while unlocked, and no medications should be left out on the carts. 10 New York Codes, Rules and Regulations 415.18(d)

Based on observations and interviews, the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of two (2) test trays (04/28/2026 lunch and 04/29/2026 breakfast); and 12 of 17 anonymous residents present at the Resident Council meeting and two (2) of two (2) residents (Residents #346 and #20) interviewed. Specifically, the 04/28/2026 lunch tray and the 04/29/2026 breakfast tray included hot foods served below 140 degrees Fahrenheit and cold foods served above 41 degrees Fahrenheit and were not palatable; 12 anonymous residents at the Resident Council meeting stated the food was cold and overcooked; and Residents #346 and #20 stated the food was not palatable.Findings include: The facility policy Food Temperatures, dated 5/28/2025, documented hot food would be served at no less than 140 degrees Fahrenheit and cold food would be served no higher than 41 degrees Fahrenheit. Appropriate food transport equipment to maintain safe temperatures would be utilized. During an interview on 04/27/2026 at 11:05 AM, Resident #346 stated the food was not good. During an interview on 04/27/2026 at 1:21 PM, Resident #20 stated they did not always get what they preferred on their meal trays and the food was cold at times. During a Resident Council meeting with surveyors on 04/27/2026 at 2:00 PM, 12 anonymous residents stated the food was not palatable, was cold at times, at times the meat was too tough to eat or to cut with plastic utensils, and food was sometimes inconsistent with their meal tickets. During a meal observation on 04/27/2026 at 1:31 PM, the meal tray cart arrived on Unit C south. There were six (6) trays not in the cart and four (4) on the cart did not have their lid tight. The first tray was passed at 1:42 PM. At 1:44 PM, the tray cart door remained open. At 1:57 PM, there were two (2) trays remaining within the open-door cart. Those trays remained as they were refused by their respective residents. During an observation on 04/28/2026 at 1:47 PM, Resident #270's meal was used as a test tray with the resident's permission, and a replacement was ordered. The following food temperatures were verified with Certified Nurse Aide #30: -4-ounce turkey meatloaf was 128.7 degrees Fahrenheit. -1/2 cup garden rice was 135.1 degrees Fahrenheit and tasted bland. -1/2 cup yellow squash was 135 degrees Fahrenheit and was mushy in consistency; and -4-ounce milk was 55.2 degrees Fahrenheit. During an interview on 04/28/2026 at 2:31 PM, Certified Nurse Aide #30 stated many residents complained the food was late, the food was cold, and Unit C was usually the last floor served. Certified Nurse Aide #30 pointed out a sign documenting unit breakfast service was at 9:30 AM and lunch service was at 1:20 PM. The aide stated the food looked unappetizing. During an observation on 04/29/2026 at 9:50 AM, Resident #270's breakfast tray was used as a test tray, and a replacement was ordered. The following food temperatures were verified with Certified Nurse Aide #30: -Milk was 51.4 degrees Fahrenheit. -Apple Juice was 53.2 degrees Fahrenheit. - Biscuit with 2 ounces of sausage gravy was 117 degrees Fahrenheit and tasted cool and the biscuit was hard to chew; and -Oatmeal 6 ounces was 147.7 degrees Fahrenheit and tasted bland. During an interview on 04/29/2026 at 12:12 PM, Licensed Practical Nurse #25 stated there were many residents who complained about the food being cold, small portions, and it did not taste good. Residents also complained they did not get what they wanted. When that happened, a sandwich or substitute was offered, and the kitchen was notified. During an interview on 05/01/2026 at 12:05 PM, Dietary Supervisor #51 stated the cold production side of the tray line handled all cold products. Every resident had a meal ticket that was placed on the tray to ensure the resident received the appropriate food and drink items. Plates were kept in a hot box prior to use and were covered with a lid once plated. The tray went down the tray line with hot foods plated first and cold food/drink items paced last before each tray went on the food cart to be delivered to the unit. The loader was the last staff member to ensure accuracy of the tray. It took about 10 minutes to complete each unit's tray service and cart load and then the cart went immediately to the designated unit. Alternates were available. Food temperatures were checked on the tray line numerous times by the cook. Hot foods should be above 140 degrees Fahrenheit and cold foods should be less than 41 degrees Fahrenheit when delivered to the residents. During an interview on 04/30/2026 at 12:26 PM, Licensed Practical Nurse Manager #5 stated multiple residents complained the food received was not what they wanted, was cold, or that it was late. They stated they contacted the kitchen for a replacement or for missing food items, and unit staff did the same for food related concerns. Food should be hot and tasty. 10 New York Codes, Rules, and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews, the facility failed to ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for two (2) of two (2) residents (Residents #267 and #290) reviewed. Specifically, Resident #267 alleged they were sexually abused and Resident #290 alleged they were physically and verbally abused and there was no documented evidence the facility completed a thorough investigation in response to the allegations or reported the allegations to the New York State Department of Health as required. Findings include:The facility policy Resident Rights, last reviewed on 05/28/2024 documented health care personnel shall treat all residents with kindness, respect and dignity. The facility policy Abuse, revised 07/18/2025, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. Definitions of verbal abuse are oral, written or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient. Sexual abuse is non-consensual sexual contact of any type with a resident and includes, but is not limited to, humiliation, harassment, coercion or assault. 1) Resident #267 had diagnoses including depression, anxiety, and Alzheimer's disease. The 03/25/2026 Minimum Data Set assessment documented the resident had severely impaired cognition; anxiety and depression; hallucinated; had physical and verbal behavioral symptoms directed toward others; rejected care 4- 6 days but less than daily; was always incontinent of urine and bowel and received antianxiety medication daily. During an observation and interview on 04/27/2026 at 2:06 PM, Resident #267 was heard in their room yelling out they were sexually assaulted by [expletive] [cultural reference to country of origin]. Upon entering the room, the resident stated those [cultural reference to country of origin] raped them. The resident stated they wanted to speak to the head nurse. At 2:07 PM, upon exiting the resident's room Licensed Practical Nurse #63 informed the surveyor the resident yelled out all the time that the nurse aides were raping them. The resident called the staff racial slurs and threw random objects at them. The comprehensive care plan documented: -initiated 06/10/2022, and revised on 06/21/2023, the resident had actual resident to resident altercations as evidenced by throwing objects, yelling, and using foul language. Interventions included attempt to provide emotional support when the resident was angry, remove environmental triggers, and refer to psychiatry services. There were no documented behaviors of accusations of sexual assault or racial slurs. -initiated on 01/13/2023 and revised on 06/05/2025, the resident exhibited behavioral symptoms such as depressed mood, verbal and physical aggression toward staff when care was provided and refused to be positioned in bed for safety. Interventions included when behaviors occurred, verbally redirect the resident, acknowledge the resident's feelings, approach in a calm manner, and explain why the care was needed. There were no documented behaviors of accusations of sexual assault or racial slursThe 03/10/2026 Nurse Practitioner #32 progress note documented the resident had a history of dementia with psychotic disturbance. The resident had disorganized thought process and mood was labile, ranging from pleasant to irritable within a short span of conversation. They had limited insight secondary to severe dementia. The 04/06/2026 at 1:37 PM, Social Worker #60 progress note documented a care plan meeting was held. The resident was not in attendance. There was no documentation the resident had a history of accusations of sexual assault. There was no documented evidence progress notes the resident reported being sexually assaulted. There was no evidence that the facility initiated an investigation for the alleged abuse or facility reported incidents related to sexual assault on file with the New York State Department of Health. During an interview on 04/28/2026 at 2:16 PM, Certified Nurse Aide #62 stated the resident made false accusation about the staff and said staff touched them and they were raped. They stated every time staff did the resident's urinary catheter care the resident used racial slurs. They told administration staff about the behaviors. The solution was to rotate the resident assigned care giver. During an interview on 04/29/2026 at 06:23 AM, Licensed Practical Nurse Unit Manager #61 stated Resident #267 called staff names and yelled out the staff were raping them when completing the resident's personal care. They stated they had not told the nursing supervisor about these comments. The resident was care planned for behaviors. The resident used to be on another floor, and they were not sure if the accusations of rape had been investigated. During an interview on 04/29/2026 at 11:18 AM, the Acting Director of Nursing stated they never heard the resident call out they were being raped. The resident did call the staff vulgar and racist names. They thought the resident was care planned for these behaviors. Anyone who heard the resident say they were raped, should complete a statement, and report to the supervisor and the medical provider. The resident would need a medical exam, and the police would have to be called. At this point, they were not aware of any incident reports for the resident regarding rape. This should have been reported immediately to the unit manager, and the unit manager should report to the supervisor who would complete an investigation and update the care plan after the investigation was completed. During an interview on 04/30/2026 at 11:53 AM, Nurse Practitioner #4 stated if there were accusations of rape, they would have been asked to complete an evaluation. The resident did mention to them they were raped by someone who worked at the facility but was not a nurse. They asked the resident if they felt they were being raped during personal care and the resident said yes. The resident said they felt like they were being violated when they were cleaned up after being incontinent. The resident stated they did not have any pain in their perineal area and did not answer any questions about their penis. They stated they thought the resident was associating their perineal care with being raped. 2) Resident #290 had diagnoses including depression. The 01/16/2026 Minimum Data Set assessment documented the resident had intact cognition; felt down or depressed in the last two to six days; had no behaviors; and was dependent on staff for most of their activities of daily living. The comprehensive care plan initiated on 11/18/2025 and updated on 03/29/2026, documented the resident exhibited behaviors such as mood changes, withdrawn, changes in appetites, and sleep disturbance related to depression. Interventions included checking the resident for toileting needs, providing care as indicated, determining the cause of the behaviors, distracting resident with preferred activities, and initiating psychiatric evaluation as needed. During an interview on 04/28/2026 at 9:24 AM, Resident #290 stated most of the staff do a good job, but there was one aide on the evening shift that was not good to them. They could not recall the aide's name, but they were mean, called them names, and hurt their leg. They stated they had their family member call the unit manager. They had not seen the nurse aide that was mean since that day, could not remember when it was, but the aide was removed from their care assignment. During a telephone interview on 04/28/2026 at 3:17 PM, the resident's emergency contact stated Resident #290 was coherent and able to make their needs known. They stated there was an incident where a nurse aide refused to turn and position the resident and said they would not help because the resident was too large. They stated this happened at the end of February 2026 or beginning of March 2026. They were not sure what the aide's name was because the aide refused to tell the resident their name. They called the Administrator multiple times, and they were transferred to voicemail or staff would tell them the Administrator did not want to talk to them. There was no documented evidence in the 02/13/2026 to 03/31/2026 nursing progress notes of the resident's reports of being verbally abused by nursing staff. There were no documented social work progress notes addressing the resident's allegations of abuse by a certified nurse aide. There were no documented facility reported incidents related to sexual assault with New York State Department of Health. There was no evidence that the facility initiated an investigation into the accusations of alleged abuse of Resident #290 During an interview on 04/30/2026 at 8:43 AM, Certified Nurse Aide #59 stated they took care of Resident #290 every other day; the resident was dependent on two staff for rolling and their personal care needs. They were not aware of any staff who was mean to the resident. If they heard someone call the resident names, or be disrespectful, they would report that to the unit manager. They did recall there was a complaint a couple of weeks ago. The resident told them an aide would not change them and called them names. But they did not know the aide's name. During an interview on 04/30/2026 at 9:40 AM, Licensed Practical Nurse Unit Manager #20 stated they reported incident and concerns to Assistant Director of Nursing #2. There was no dedicated registered nurse on their unit, and they were required to call the Registered Nurse Supervisor or the Assistant Director of Nursing. The resident had not voiced any concerns about care, but the resident's emergency contact voiced concerns about an aide that was not speaking to the resident respectfully. They stated there were no allegations of abuse or mistreatment, just the aide's tone of voice directed at the resident was not acceptable. The nurse aide still worked on the unit, but they did not assign them to Resident #290. They did not report this incident to their supervisor. During an interview on 04/30/2026 at 12:48 PM, the Acting Director of Nursing stated they were not aware there was a nurse aide that was mean to Resident #290. They called Licensed Practical Nurse Unit Manager #20 during the interview and inquired about the incident. They were told by Licensed Practical Nurse Unit Manager #20 there was an incident about a month ago with Certified Nurse Aide # 58 and Resident #290. They did not complete an incident report and just removed Certified Nurse Aide #58 from Resident #290's assignment. The Acting Director of Nursing stated the unit manager should have reported this immediately to the Registered Nurse Supervisor so they could follow up with the resident, the family and notify medical and complete an investigation to rule out abuse. 10 New York Codes Rules Regulations 415.4(b)(3)

Based on observations, record review, and interviews (iQIES Intake 2799654, 2969603, and 2969139) the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (1) of eight (8) residents (Resident #100) reviewed. Specifically Resident #100 was not toileted or changed when they were soiled. Findings include:Resident #100 had diagnoses including hemiplegia (one sided loss of function) following a stroke, depression, and morbid obesity. The 04/13/2026 Minimum Data Set assessment documented the resident had intact cognition, required substantial/maximum assistance with showering, was dependent on toileting and rolling in bed, was frequently incontinent of urine and bowel, was at risk for developing pressure injuries, had unhealed pressure injuries, had three Stage 2 (partial thickness tissue loss) pressure ulcers, and did not reject care.The comprehensive care plan documented:-initiated 04/12/2024 and revised 09/16/2025, the resident had bowel incontinence related to impaired mobility and hemiplegia. Interventions included toileting every 2-4 hours with peri care after each incontinent episode.-initiated 05/11/2024 and revised 10/01/2024, the resident had bladder incontinence related to impaired mobility, diabetes, and history of prostate cancer. Interventions included application of incontinence devices, provide toileting care every 2-4 hours, and monitor for signs of urinary tract infection including pain, burning, blood-tinged urine, frequency, and changes in behavior. The undated certified nurse care instructions documented the resident required being checked and provided toileting care every 2-4 hours and the resident was dependent on staff for toileting needs.The Certified Nurse Aide documentation documented bowel and bladder toileting care every 2-4 hours care was not completed for Resident #100 on:Day shifts on 02/03/2026, 02/13/2026, 03/18/2026, 03/21/2026, 04/01/2026, 04/04/2026, and 04/13/2026.Evening shifts on 02/15/2026, 03/15/2026, 0323/2026, 03/28/2026, 04/12/2026, 04/17/2026, 04/19/2026, 04/20/2026, and 04/26/2026. Night shifts on 02/09/2026, 02/10/2026, 02/11/2026, 02/13/2026, 02/15/2026, 02/17/2026, 02/23/2026, 02/24/2026, 02/25/2026, 02/28/2026, 03/23/2026, 03/31/2026, 04/23/2026, 04/25/2026, and 04/30/2026. During an observation and interview on 04/27/2026 at 9:54 AM, Resident #100 was in bed on their back in bed. They stated they were not cleaned when they were wet or soiled and now, they had sores on their buttocks. They were unable to move independently because they had a stroke. The following was observed during an uninterrupted observation on 04/29/2026 from 4:42 AM until 10:26 AM: -at 5:40 AM, an unidentified certified nurse aide from the south unit entered the resident's room and removed a clean brief from the resident's dresser and left the room, they did not provide care to the resident. -at 8:10 AM Certified Nurse Aide #30 entered the room, the resident was observed on their back, stated they were wet, and wanted a cup of hot water. Certified Nurse Aide #30 did not check or change the resident or return with their hot water. -No care was provided to the resident from 8:10 AM-10:26 AM. During an observation and interview on 04/29/2026 at 10:26 AM, Certified Nurse Aide #68 stated they normally provided care to Resident #100 around 11:00 AM however, they were starting early because the resident was getting a treatment to their buttocks by physical therapy at 11:00 AM. Certified Nurse Aide #68 asked Certified Nurse Aide #30 for assistance with providing care because the resident required assistance of two for bathing and changing. The resident was wearing an adult incontinent brief that was saturated with urine and had a large amount of loose brown stool. Certified Nurse Aide #30 stated the resident was soaked with urine many times when they worked and was left soaked from the night shift. They stated when residents were not checked and changed, they could develop skin breakdown, and Resident #100 had skin breakdown on their buttocks and upper thigh. Resident #100 stated they spoke to Licensed Practical Nurse Unit Manager #5 and set up a turning and toileting schedule which was agreed to be completed every 2 hours, however not every staff completed this. During an interview on 05/01/2026 at 12:02 PM Physician #38 stated it was important to keep residents clean and dry to prevent skin breakdown and promote wound healing. Incontinent residents should be checked every 2 hours to ensure they were not wet or soiled. When a resident had a known area of skin breakdown on their buttocks it was even more important for them to be changed frequently as urine and stool could contaminate the wound and impede wound healing. It only took 9 minutes of sitting in urine or stool for tissue to be impacted and 90 minutes of sitting in urine or stool for a wound to develop. During an interview on 05/01/2026 at 1:19 PM, Licensed Practical Nurse #27 stated it was important to turn and position residents and keep them dry to promote good skin integrity and prevent skin breakdown. They should be checked every 2 hours with particular attention to incontinent residents. Residents should not be in the same position, wet, or soiled for 6 hours. Resident #100 was a priority for checking and changing because they were incontinent and had skin breakdown. During an interview on 05/01/2026 at 2:40 PM, Licensed Practical Nurse Unit Manager #5 stated they expected certified nurse aides to complete rounds every 2 hours to check for incontinence and reposition residents in effort to prevent moisture associated skin damage and skin breakdown. Resident #100 was incontinent of urine and stool, was dependent on two for turning and changing wet or soiled incontinent briefs, and had both moisture associated skin damage and skin breakdown. Night shift staff should complete incontinent care before leaving their shift. 10 New York Codes Rules Regulations 415.12(a)(3)

Based on observations, record review, and interviews (IQIES intakes 2796359 and 2984903), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #15) reviewed. Specifically, Resident #15 sustained a fall, was transferred to the hospital, returned to the facility with a fractured clavicle (collarbone), medical was not notified to address the fracture, a sling was not ordered as recommended, and there was no documented evidence the resident received an orthopedic follow up consultation as recommended. Findings include:The facility policy Change in Condition Notification, dated 08/2019, documented it was the facility policy to monitor residents for changes in their condition, to respond appropriately to those changes and to notify the physician and responsible party/family members of changes. The licensed nurse will record in the resident's medical record any significant changes in the resident's condition or medical status.The facility policy Change in Resident's Condition, last revised 05/2019, documented the facility should promptly notify the resident, their attending physician and the representative of changes in their medical condition. The nurse will notify the resident physician or on call physician when there has been an accident or incident involving the resident. The nurse will record in the resident's medical record information relative to changes in the resident medical or mental condition or status.Resident #15 had diagnoses including Alzheimer's, dementia, and muscle wasting. The 02/25/2026 Mininim Data Set documented the resident had severe cognitive impairment; did not reject care; used a walker; and required supervision for transfers and walking.The Comprehensive Care Plan initiated 02/10/2026 documented the resident required assistance with self-care and mobility related to confusion and dementia. Interventions included anticipating the resident's needs, call bell placed in reach, ensure the resident wears appropriate footwear for movement, and maintain a clutter free environment. The resident was at risk for falls related to confusion, incontinence, and poor communication. Interventions included pain evaluation, physical therapy to evaluate and treat as ordered, and provide a well-lit environment. The 02/10/2026 at 2:00 PM, Full Quality Assurance Report initiated by Licensed Practical Nurse Unit Manager #19 documented Resident #15 had a fall in the hallway/corridor while ambulating. The fall was witnessed by a staff member and was reported to Nurse Practitioner #4. The ambulance was called, and the resident was sent to the local hospital. The resident was newly admitted with diagnosis of dementia, was ambulating around the unit, and was found on the floor, lying on their right shoulder. The resident complained of pain to the right shoulder. The resident went to hospital to rule out a fracture to the right shoulder.The 02/10/2026 emergency room Triage progress note documented the resident had a witnessed fall at the nursing home. The resident hit their head and had just recently started Eliquis (a blood thinner) three days ago. This was their first day at that facility and they were wearing slippery socks. The computerized tomography scan (a quick detailed x-ray) of the spine was completed, and the resident sustained an acute right clavicle fracture. The resident was discharged home with follow up with an orthopedic provider and placed in sling.The 02/10/2026 at 9:35 PM, Registered Nurse #49 progress note documented the resident returned from the hospital at 9:00 PM with a new diagnosis of a closed fracture to the right clavicle. There was no documentation the medical provider was notified or an order for a sling was placed.There was no documented evidence the Physical Therapist #70 physical therapy discharge summary for service dates of 02/10/2026-02/19/2026 included a diagnosis or treatment plan for a fractured clavicle. There was no documented evidence of nursing notes addressing the resident's clavicle fracture or use of a sling from 02/11/2026-2/26/2026. The 02/27/2026 at 2:48 PM, Licensed Practical Nurse Unit Manager #19 progress note documented the local orthopedic practice sent a facsimile order for an x-ray of the right clavicle, and routine Tylenol every eight hours for pain. There was no documented evidence the resident attended an appointment with the orthopedic practice. The 02/27/2026 physician order documented right clavicle imaging to be completed for abnormal mobility.The 02/27/2026 Radiology Results Report documented the resident had a right acute clavicle displaced fracture with osteopenia and arthritic changes.The 03/05/2026 at 1:53 PM, Physician #31 30-day progress note documented that the resident had an unwitnessed fall and sustained a right clavicular fracture, and the resident had bruising to their chest. The resident denied pain in the area.The 03/30/2026 orthopedic consult report documented the resident was seen and was referred to their practice by the emergency department for right clavicle after being seen in the emergency room on [DATE]. The resident had a fracture to right distal clavicle, initially evaluated at the hospital on [DATE]. Physical therapy was recommended for shoulder active and passive motion. Pain control measures were discussed, and the resident would be reassessed in four weeks to ensure progress. There was no documented evidence the orthopedic specialist was aware the resident had not worn a sling after discharge from the emergency department on 02/10/2026. During an interview on 04/30/2026 at 9:01 AM, Certified Nurse Aide #33 stated Resident #15 had a fall in 02/2026 and went to the hospital and returned the same day. They had to be reevaluated by therapy. They did not recall if the resident had a sling but there was a lot of bruising on their chest. During a telephone interview on 04/30/2026 at 9:26 AM, Registered Nurse Supervisor #49stated when a resident returned from the hospital they did an assessment, checked their vital signs, checked the hospital paperwork and called the provider on call and put in any new orders, including follow up appointments. They entered a progress note in the record they had notified the on-call provider. They recalled the resident had a fracture. They stated they would have notified the provider upon the resident's return and there should be a progress note for the notification. They did not recall if the resident had a cast or a sling. There was a meeting the next day to follow up on the resident. There was a report sheet in the supervisor's office, to make note on any admissions, change in conditions, or anything irregular. If the resident had a fracture, they should have medical follow up and an orthopedic consultation. During an interview on 04/30/2026 at 11:00 AM, Licensed Practical Nurse Unit Manager #19 stated if a resident returned from the emergency in less than 24 hours they reviewed the after-visit summary with Nurse Practitioner #4, and they wrote down on the paperwork what Nurse Practitioner #4 wanted ordered. When a resident returned during off hours, the nursing supervisor was notified and would go to the resident unit. They were supposed to call the on-call provider, verify if there were new orders and notify the family. If the after-visit summary included a consultation, the consultation was entered in the record as an order. The physician liaison would follow up on this. If there was no after visit summary from the hospital, the supervisor should call the hospital. Resident #15 fell within the first day of admission and the nurse practitioner ordered to send the resident to the emergency room. The resident returned to the facility and there was an orthopedic consultant. They remembered putting the order in and communicating it. They were not sure if the resident was ever seen by the orthopedics team. The resident had a right closed fracture of the clavicle. Medical should be notified and there should have been a progress note that medical was notified. During an interview on 04/30/2026 at 11:22 AM, Physician Liaison #36 stated they set up all the appointments. They run a report to see who needs appointments, but if the nurses did not put an order in under consultants they would not know about it. Resident #15 went to the local orthopedic provider on 03/30/2026. During an interview on 04/30/2026 at 12:41 PM, the interim Director of Nursing stated when the resident returned from the emergency room, they get the paperwork and do an assessment and notify the family the resident was back. They provided the nurse practitioner with the new orders. If the hospital did not send anything, they called for records. If the resident had to go to a specialist, there would be an interdisciplinary team meeting form completed with the recommendation. They would review with the health care provider and notify the family of any changes. During a telephone interview on 04/30/2026 at 2:31 PM, Physician #31 stated if a resident was sent to the emergency room medical would see the resident when they returned from the hospital. They reviewed anyone who went to the emergency room every Wednesday. They reviewed the discharge summary or after visit summary. They stated there was a summary of an episode on the 02/10/2026 with Resident #15. They missed that one and was not told about the incident. They would have wanted to know about the fall, because the fall could interfere with the resident's daily activities and the resident was on blood thinners. If the emergency room identified the clavicle fracture, they would have placed a sling and called for an orthopedic consultation. The resident would need an order for the sling while at the nursing home and the resident would benefit from the use of a sling. They stated if staff did not notify them, they would only know if they went through their electronic chart. 10 New York Codes Rules Regulations 415.12

Based on observations, record review, and interviews the facility failed to ensure that residents who required dialysis services (a process that filters blood when the kidneys do not work efficiently) received such services consistent with professional standards of practice for one (1) of two (2) residents (Resident #70) reviewed. Specifically, Resident #70 did not have their fistula site (access for dialysis) checked and dressing removed as ordered and did not consistently have post dialysis assessments completed. Findings Include:Resident #70 had diagnoses including end stage kidney disease and dependence on dialysis. The 04/03/2026 Minimum Data Set assessment documented the resident had moderate cognitive impairment and required dialysis treatment.The comprehensive care plan initiated 10/01/2025 documented the resident received dialysis on Tuesdays, Thursdays, and Saturdays. Interventions included checking arteriovenous fistula in the left arm; monitor for bruit (sound caused by turbulent blood flow through fistula) and thrill (buzzing vibration felt with a fistula) every shift and document pre and post dialysis assessments.The 09/30/2025 physician order documented arteriovenous fistula, monitor for bruit and thrill every shift; notify the physician for absence; monitor the fistula for bleeding; if bleeding noted apply pressure and notify physician. The 01/20/2026 physician order documented remove the dressing to the left arm fistula after dialysis every day shift; every Wednesday, Friday, and Sunday. Resident #70's pre-dialysis progress notes dated 03/31/2026, 04/02/2026, 04/04/2026, 04/07/2026, 04/09/2027, 04/11/2026, 04/14/2026, 04/16/2026, 04/21/2026, 04/23/2026, 04/25/2026, and 04/28/2026, documented the resident attended dialysis. There were no documented post dialysis assessments/progress notes documented on 03/31/2026, 04/02/2026, and 04/21/2026 when the resident attended dialysis.The April 2026 treatment administration record did not include monitoring of the resident fistula 04/07/2026 on the evening shift, 04/20/2026 day shift, or 04/26/2026 evening shift.During an interview on 04/30/2026 at 10:51 AM, Licensed Practical Nurse Unit Manager #19 stated the resident attended dialysis and had a fistula located on the left arm. They stated it was important the access site was monitored before and after dialysis treatment, as it was an emergency if bleeding occurred. They stated vital signs were taken before and after dialysis and documented; and they believed the dressing was removed post dialysis.During an interview on 04/30/2026 at 12:31 PM, the Acting Director of Nursing stated assessments were supposed to occur before and after dialysis. Information about treatment was retrieved from the dialysis documentation and needed to complete the post dialysis assessment. The Director of Nursing stated if the there was no pre or post assessment documented, it was not a completed assessment 10 New York State Codes Rules and Regulations 415.11(a)(5)

Based on observations, record review, and interview, the facility failed to ensure that licensed nurses had the appropriate competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for three (3) of three (3) licensed nurses (Licensed Practical Nurses #9 and #10, and Registered Nurse #13) reviewed. Specifically, Licensed Practical Nurses #9 and #10 performed wound assessments without registered nurse direct oversight; Registered Nurse #13 failed to identify and stage wounds on Resident #179's right and left legs; and Licensed Practical Nurses #9 and #10 and Registered Nurse #13 did not have competencies for wound care as part of the facility's designated wound care team. Substandard of Care was identified in treatment and services to prevent and heal pressure ulcers (F686).Findings included:The facility policy Wound Identification and Wound Rounds, revised 11/06/2023, documented the facility would identify, assess, and manage residents with pressure injuries, skin alterations, impairments, or wounds in accordance with current standards of practice. The registered nurse completed an initial wound assessment that included shape, size, depth and staging. A designated wound nurse or licensed nurse completed weekly wound rounds with a wound provider. Wounds were measured and assessed weekly and documented in the resident's electronic medical record in the Licensed Nurse: weekly wound evaluation and/or Wound care provider progress note. The facility policy Skin and Pressure Injury Prevention, revised 06/27/2024, documented residents were assessed on admission and re-admission for existing pressure and injury risk factors utilizing the Braden Risk Assessment (scale for predicting pressure). Braden Assessments were also conducted upon any change in resident condition.There was no documented facility policy for nursing assessments and assessment accuracy.The Facility Assessment Portfolio, revised 03/2026, documented specific care or practices included pressure injury prevention and care, skin care, wound care, and early identification of problems/deterioration. Upon hiring, all facility personnel participated in general orientation and job specific orientation. Each facility department had job specific orientation with pertinent training topics and policy/procedures for that discipline, with job specific curriculum and job specific competencies. Registered nurses and licensed practical nurses received one day of general orientation and two days of classroom training, preceptorship, and further training as determined by nursing leadership. Required competencies included person centered care and treatment competency.During an observation and interview on 05/05/2026 at 11:13 AM, Registered Nurse #13 assessed Resident #179's pressure wound. They stated they had last seen the wound two weeks prior and did not remember what it looked like. They removed the dressing from the left ankle and measured the wound as 1.2 centimeters by 1.4 centimeters and assessed the wound as a Stage 2 (partial-thickness skin loss with pink or red wound bed) pressure ulcer. Registered Nurse #13 stated they were unable to visualize the wound bed. They stated they did not notice the wound immediately above the right ankle wound. Licensed Practical Nurse #10 obscured the right ankle wound by placing their hand over the wound. They assessed the new wound as a Stage 2 pressure ulcer and measured it as 1.0 centimeter by 0.4 centimeter. The resident's leg was lying directly on a pillow, and an undated dressing was observed on the left lower lateral (outside) leg. Registered Nurse #13 stated they were unaware of the left outer ankle wound. They assessed it as a Stage 3 (full thickness tissue loss) pressure wound and measured it clustered by 4.3 centimeter by 1.0 centimeter. They stated they would inform the provider of the newly identified wounds. No further skin assessment was conducted.The facility document Clinical Competency Assessment, revised 12/2024, documented skills for dressing: aseptic/clean and wound vacuum assisted closure devices.There was no documentation provided for the qualifications of wound team nurses or specific wound team education. Nursing personnel records documented the most current completed competencies as followed:Licensed Practical Nurse #9 had demonstrated skills:- Dressing: aseptic/clean, completed on 04/23/2025.- Wound vacuum assisted closure device, completed on 12/15/2025.There was no documented evidence of wound evaluation and Braden Risk Assessment education provided.Licensed Practical Nurse #10 had demonstrated skills:- Dressing: aseptic/clean, completed on 11/06/2024.- Wound vacuum assisted closure device, completed on 12/15.There was no documented evidence of wound evaluation and Braden Risk Assessment education provided.Registered Nurse #13 had demonstrated skills:- Dressing: aseptic/clean, completed on 12/17/2025.- Wound vacuum assisted closure device, completed on 12/15/2025.There was no documented evidence of wound assessment and Braden Risk Assessment education provided.During an interview on 05/01/2026 at 12:23 PM, Licensed Practical Nurse #9 stated they were part of the wound team along with Licensed Practical Nurse #10 and Registered Nurse #13. Occasionally a provider or registered nurse would sign off on their notes. If a wound was healing or resolved they updated a registered nurse, however, they were not always able to find a registered nurse. They stated they probably should not document a wound as healed or resolved, as that was an assessment. The wound team rounded together and wrote down the measurements and assessments on paper then split up the residents and documented on the wound in the electronic medical record. They stated they could document data that was obtained by someone else. During an interview on 05/01/2026 at 1:19 PM, Licensed Practical Nurse #10 stated they documented that Resident #13's wound was healed and resolved it in the electronic medical record. They did not tell a registered nurse since the wound team registered nurse was not available. They should not have assessed and documented the wound as resolved; the registered nurse should have assessed the wound and resolved it. It was not possible to know if a registered nurse or provider attended wound rounds with them as there was no co-signature or documentation of such. During an interview on 05/01/2026 at 1:46 PM, Assistant Director of Nursing #3 stated the Braden Risk Assessment was reviewed by registered nurses. The licensed practical nurse would start the Braden Risk Assessment, but a registered nurse finished the assessment and signed it. Licensed practical nurses should not document if a wound was healed or resolved. The registered nurse needed to assess the wound and write a note. During an interview on 05/01/2026 at 2:06 PM, Registered Nurse #13 stated they were part of the wound team and had not received specific training on wounds. They performed and documented the initial wound assessments. They were unsure what a licensed practical nurse could document versus what was considered an assessment. The licensed practical nurse informed a registered nurse if the wound was worsening. A registered nurse or wound provider should assess the wound and document on the wound.During an interview on 05/05/2026 at 12:07 PM, the Administrator stated they had a wound team consisting of Registered Nurse #13, Licensed Practical Nurse #9, and Licensed Practical Nurse #10. They did not know how often the wound team rounded. They did not know the scope of practice for licensed practical nurses or registered nurses. They were unsure if the wound team received education related to wounds. During an interview on 05/05/2026 at 12:25 PM, Nurse Consultant #69 stated licensed practical nurses were able to follow and evaluate wounds since an initial assessment was completed by a registered nurse and the registered nurse and provider accompanied them on wound rounds. The wound note was structured so the licensed practical nurse could document. Licensed practical nurses just collected data in collaboration with the wound care provider. There was a gap in time when there was no wound care provider. There was an area on the wound note to document that the provider was present during the evaluation. 10 New York Codes, Rules and Regulations 415.26(c)(1)(iv)

Based on observations, record review, and interviews (iQIES Intake 2969603) the facility failed to ensure that residents were free of any significant medication errors for one (1) of two (2) resident (Resident #209) reviewed. Specifically, Resident #209 had a physician order for baclofen (a muscle relaxant and antispasmodic used to treat neurological conditions) four times a day and the medication was not administered within the prescribed time frame causing the resident discomfort. Findings include:The facility policy Medication Administration, last revised 12/2019, documented medications were administered in a safe and timely manner as prescribed. Medications were administered in accordance with the order including any time frame. Medications must not be prepared in advance and must be administered within (1) one hour of the prescribed time unless otherwise specified. If a medication was withheld, refused, or given at a time other than the scheduled time, the individual administering the medication should document as such in a designated format. Resident #209 had diagnoses including multiple sclerosis (a progressive central nervous system disease) and muscle weakness. The 04/01/2026 Minimum Data Set assessment documented the resident had intact cognition and frequently had pain that affected their sleep and interfered with day to day activities with a reported pain rating of 7 (seven). The 10/23/2025 Comprehensive Care Plan, revised 03/29/2026, documented the resident had an alteration in comfort related to multiple sclerosis, limited mobility, trauma, pressure wounds, and muscle spasms. Interventions included administering medications as ordered, evaluating the effectiveness of pain interventions, reviewing for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, and using non-pharmacological interventions to promote comfort.The 04/20/2026 physician order documented baclofen 10 milligrams, give three tablets by mouth four times a day for muscle spasms.The April 2026 Medication Administration Record documented baclofen 10 milligrams give three tablets four times a day at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. Baclofen 10 milligrams three tables were administered:-on 04/24/2026 at 11:01 AM by Licensed Practical Nurse #27 (2 hours late).-on 04/24/2026 at 2:27 PM by Licensed Practical Nurse #27 (1 hour and 27 minutes late). -on 04/24/2026 at 6:20 PM by Licensed Practical Nurse #52 (1 hour and 20 minutes late).-on 04/24/2026 at 8:07 PM by Licensed Practical Nurse #52 (within the prescribed timeframe, but 1 hour and 47 minutes after the previous dose was administered).-on 04/28/2026 at 2:32 PM by Licensed Practical Nurse #53 (32 minutes late).-on 04/30/2026 at 10:48 AM by Licensed Practical Nurse #12 (48 minutes late).There were no documented nursing progress reports regarding the late medication administration times of baclofen.The 03/18/2026 Physician #31 progress note documented they evaluated the resident for primary progressive multiple sclerosis, neuropathy, and reduced mobility. The resident's spasticity remained severe and uncomfortable and had only ever been treated with baclofen. The resident was to be seen at an upcoming appointment by a neurologist for further management.During an observation and interview on 04/30/2026 at 8:35 AM, Resident #209 stated they were prescribed baclofen four times a day and often received the first dose after 10:00 AM. When they were home, they took the medication first thing in the morning as it helped decrease pain and improve mobility. When they received the first dose of baclofen after 10:00 AM and received a second dose at 1:00 PM, the doses were too close together. They were on the medication for 30 years and when it was not properly administered at the prescribed times, they felt sick, nauseated, and had increased pain from muscle spasms. They stated at times they were unable to get out of bed because of the pain and muscle spasms. During an interview on 04/30/2026 at 1:17 PM, Licensed Practical Nurse #27 stated they were responsible for administering medications. Some medications were prescribed for administration at 8:00 AM and others for 9:00 AM allowing for staggering administration times so medications were administered according to the physician's order. All medications could be administered 1 hour before the assigned time or up to 1 hour after the assigned time. When a medication was ordered at 9:00 AM it could be administered any time between 8:00 AM and 10:00 AM. When a medication was administered outside the ordered timeframe, they notified the supervisor. They believed the supervisor then notified the provider to ensure the medication could be administered outside the prescribed timeframe and documented it in a progress note. They stated it was important for residents to get the medications as ordered because they could interact if given too far apart or too close together. They administered Resident #209's 9:00 AM dose of baclofen on 04/30/2026 at 10:48 AM, the 9:00 AM dose on 04/24/2026 at 11:01 AM, and the 1:00 PM dose on 04/24/2026 at 2:27 PM. All the medications were administered late, and they did not notify the supervisor. Medications were administered late because breakfast trays were always late, they had insulins to administer, and trays to pass. During an interview on 05/01/2026 at 2:30 PM, Licensed Practical Nurse Unit Manager #5 stated they expected medications to be administered according to the physician's orders, the correct medication, correct dose, correct resident, and correct time. Medication administration had a window of time from 1 hour before the administration time until 1 hour after the administration time. Medications should be administered as ordered because they might interfere with other medications or could have side effects when given too close together. When a resident refused medications or they were administered outside the prescribed timeframe, they should be notified by the medication nurse, and a progress note should be written by the medication nurse. Resident #209 complained their baclofen was not always administered at the prescribed times. It was important for baclofen to be administered on time because without it Resident # 209 could not function throughout the day. Medications administered on 04/24/2026 at 11:01 AM, 04/24/2026 at 2:27 PM, 04/24/2026 at 6:20 PM, 04/24/2026 at 8:07 PM, 04/26/2026 at 10:18 AM, 04/26/2026 at 2:04 PM, 04/28/2026 at 2:32 PM, and 04/30/2026 at 10:48 were not timely. They were not notified the medications were not administered timely and should have been. During an interview on 05/01/2026 at 3:15 PM, Nurse Practitioner #4 stated they ordered baclofen for Resident #209 to help with pain from muscle spasms from multiple sclerosis. If the medication was not administered timely as ordered, side effects included somnolence (strong desire for sleep), increased pain, increased muscle spasms, and nausea. Resident #209 was just seen by their neurologist, and the provider recommended an increase of the medication to four tablets four times a day. The resident was on a high dose of baclofen because of the significant muscle spasms. It was important for the medication to be given early so the resident could function, eat, dress, and get out of bed. It was important for the medication to not be administered too close to the previous dose because the medication needed to work more consistently. 10 New York Codes, Rules, and Regulations 415.12(m)(2)

Based on observations, record review, and interviews, the facility failed to obtain consent and review the risks and benefits of bed rails (side rails) with a resident or the resident representative prior to installation of bed rails for one (1) of one (1) resident (Resident #209) reviewed. Specifically, Resident #209 had bed rails installed, and physician orders and informed consent were not obtained, and risks and benefits were not reviewed until after the installation of the bed rails; the use of bed rails was not included in the comprehensive care plan; and there were no ongoing assessments to ensure the bed rails continued to meet the resident's needs. Findings include: The facility policy Side Rails, revised 09/2019, documented each resident was assessed for functional status on admission, readmission, and quarterly for any significant change and as needed. The rehabilitation department might also be asked to evaluate the need for side rails as determined by the interdisciplinary team. The resident and/or their representative were provided with education regarding the decision on the use of side rails and side rail use was documented in the resident care plan. Staff obtained consent for the use of side rails from the resident or their representative prior to use. An order was obtained for use of the side rails by the physician. Maintenance staff installed the side rails and the maintenance director measured and reviewed proficiency in the practice of side rail safety utilizing the bed entrapment measuring tool.Resident #209 had diagnoses including multiple sclerosis (a progressive central nervous system disease) and reduced mobility. The 04/01/2026 Minimum Data Set assessment documented the resident had intact cognition; was dependent on transfers from the bed to the chair; required partial/moderate assistance to roll in bed; and did not use bed rails.The 10/22/2025 comprehensive care plan, revised 03/29/2026, documented the resident had limited physical mobility related to multiple sclerosis. Interventions included physical therapy, occupational therapy, and assistance with position changes and bed mobility. There was no documentation on the use of side rails. The undated care card instructions did not document use of bilateral side rails, The 12/09/2025 Director of Nursing #55 (previous Director of Nursing) Interdisciplinary Team Meeting progress note documented a restraint review for the use of side rails or enabler bars per resident request. Per the rehabilitation department the resident would benefit from bilateral enabler bars (side rails). The side rail was not a restraint. The side rail/enabler bar order was in place, the care plan was reviewed, and a consent was in place.The 12/09/2025 work order documented bilateral enabler bars were added Resident #209's bed. There was no documented evidence a physician order or consent was obtained, or risk and benefits of bed rails were reviewed prior to the installation of the bed rails. The 01/05/2025 physician order documented bilateral enabler bars (approximately 1 month after the installation of the side rails). The side rail consent form documented risks of the device and was signed by Resident #209 and Licensed Practical Nurse Unit Manager #5 on 01/05/2026. During an observation and interview on 04/27/2026 at 9:32 AM, bilateral enabler bars and an over the bed trapeze were observed on Resident #209's bed. The resident stated they used the bars and trapeze every day to move in bed. During an observation on 04/30/2026 at 8:35 AM, Resident #209 used both the right and left enabler bar to move from side to side, and the over bed trapeze to move in bed. During an interview on 04/30/2026 at 10:37 AM, the Director of Rehabilitation stated side rails were only used to improve residents' independence with bed mobility. The registered nurse completed the initial assessment then physical therapy evaluated the resident for appropriate use of side rails. The interdisciplinary team met and, if agreed upon, a request for enabler bars was put in the work order system for maintenance to apply the side rails. The side rails were typically installed by maintenance that same day and within 24 hours after installation, physical therapy evaluated the resident ensuring they used the side rails appropriately. Physical therapy evaluated appropriateness of the side rails quarterly. The Director of Rehabilitation looked in the computer and was unable to locate a consent form or review of risks and benefits for the resident's bed rails. There was a physical therapy discharge note on 12/19/2025 that did not document use of side rails. The 12/24/2025 physical therapy evaluation documented the resident enabler bars, and a trapeze prior to the evaluation. During an interview on 05/01/2026 at 9:37 AM, the Director of Maintenance stated they were responsible for installing side rails. They received the request for side rails from their electronic work order system and only accepted the request from physical therapy because the rails were an entrapment risk. They measured the bed and installed the rails within 24 hours. They were unable to recall when the side rails were installed for Resident #209 because they could only access the work order system back to February 2026. They stated only the Administrator had access to work orders prior to February 2026. During an interview on 05/01/2026 at 1:19 PM, Licensed Practical Nurse #27 stated side rails were used for increased mobility in bed but were not allowed because they were illegal in nursing homes. Since side rails were considered a restraint and not allowed, they were unsure why a consent would be obtained. Resident #209 had side rails, and they were unsure how the resident got them.During an interview on 05/01/2026 at 2:19 PM, Certified Nurse Aide #65 stated when a resident needed side rails to move in bed, physical therapy did an evaluation, the physician ordered them, and maintenance installed them. Resident #209 had side rails for months but was not sure when they were installed.During an interview on 05/01/2026 at 2:40 PM, Licensed Practical Nurse Unit Manager #5 stated side rails were used by residents who required assistance with bed mobility. Prior to installation of side rails, risks and benefits were reviewed with the resident and a consent was signed because there was a risk of entrapment. Prior to use of side rails, the registered nurse completed and documented an assessment in the computer and the nurse then sent a referral to physical therapy. The registered nurse assessment and consent was required prior to notifying maintenance. The request for side rails was put into the computer system as a work order for maintenance who applied the side rails. Side rails were documented in the resident care plan. They were unsure if a physician order was required or how often the physical therapy assessments were completed. Resident #209 had side rails, did not have the side rails documented on their care plan and should have. They were not sure when the consent for the side rails was obtained for Resident #209. 10 New York Code Rules Regulations 415.12(h)(1)(2)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of six (6) residents (Residents #8 and Resident #270) reviewed. Specifically, Resident #8 was on enhanced barrier precautions and Licensed Practical Nurse #6 administered the resident's tube feeding and completed a dressing change without appropriate personal protective equipment; and Resident #270 was on enhanced barrier precautions and Licensed Practical Nurse #25 completed the resident's wound dressing without appropriate personal protective equipment. Findings include: The facility policy Personal Protective Equipment, revised 02/25/2026, documented an isolation gown is worn during high contact resident care activities when contact precautions do not apply. Gloves are worn when anticipated contact with blood or body fluids, mucous membrane contact or contact with non-intact skin.The facility Enhanced Barrier Precautions signage documented everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and gowns for high contact resident care activities, including device care or use of feeding tube, and any skin opening requiring a dressing.1) Resident #8 had diagnoses including a Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer of sacral region and bacteremia (bacteria in the blood stream). The 04/01/2026 Minimum Data Set assessment documented the resident had wounds. The 04/11/2026 Comprehensive Care Plan, revised 04/20/2026, documented the resident had colonized multidrug resistant organisms including Vancomycin Resistant Enterococci (type of bacteria). Interventions included monitor resident for worsening signs of infection, enhanced barrier precautions: wear gown and gloves when providing high contact activities at the bedside including dressing, device care and/or use or wound care; remove personal protective equipment and perform hand hygiene and reapply as necessary before providing care for another resident.Physician orders documented: -04/20/2026 enteral feeding tube dressing change every 24 hours as needed for soilage, cleanse area with soap and water or normal saline, and apply a dry dressing.-04/21/2026 enteral tube feeding, Jevity 1.5 at 51 milliliter per hour to begin at 6:00 PM, for total volume of 1800 milliliter every shift for dysphagia (difficulty swallowing). During an observation and interview on 04/30/2026 at 5:39 PM, the resident's room had an enhanced barrier precaution sign posted with a personal protective bin outside the room. Licensed Practical Nurse #6 labeled the resident's tube feeding with date and time, put on gloves, and entered the resident's room without a gown. Licensed Practical Nurse #6 opened the flush bag, went into the bathroom and put water in the flush bag, and clamped the tube. They discarded the old tube feeding container, tubing and flush bag. They changed their gloves and did not perform hand hygiene. They removed the old dressing around the residents' feeding tube site, cleansed with normal saline and applied a new dressing. They primed the tube feeding and turned on the tube feeding pump. They stated gowns were only worn when they were doing dressing changes and they did not have to wear a gown when setting up a tube feeding.2) Resident #270 had diagnoses of chronic kidney disease and cancer. The 04/03/2026 Minimum Data Set assessment documented the resident had intact cognition, had moisture associated skin damage, and application of ointment/medications. The 03/26/2026 Comprehensive Care Plan, documented the resident was at risk for impaired skin integrity related to impaired mobility, renal disease and incontinence. Interventions included applying protective skin care, minimizing extended exposure to skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing. The care plan did not include enhanced barrier precautions. The 04/17/2026 physician order documented the left shin should be cleansed with normal saline, apply a Xero foam gauze to wound bed, and cover with border gauze every shift for wound care.During observations on 04/27/2026 at 2:34 PM and 04/29/2026 at 12:00 PM, Licensed Practical Nurse #25 performed the resident's dressing change. They did not wear a gown. The enhanced barrier precautions sign outside the door to the resident's room, instructed staff to wear a gown and gloves when doing a dressing change. During an interview on 04/29/2026 at 12:12 PM, Licensed Practical Nurse #25 stated they did receive general training on infection control, but they did not know what the signs outside the resident's door meant. They did not wear a gown when doing Resident #270's dressing either day because they did not know what the signs meant. They stated they worked alone during the weekend shifts, and the personal protective equipment was not always stocked so they did not always wear a gown. Gowns were worn when doing dressing changes to prevent the spread of infection. During an interview on 04/30/2026 at 12:47 PM, Licensed Practical Nurse Unit Manager #5 stated everyone was trained in infection control and the staff received monthly training. The residents on precautions had a sign outside their room door and the sign for enhanced barrier precautions instructed staff to clean their hands, wear gloves, and gowns. The nursing staff should follow the directions to prevent the spread of infection.During an interview on 05/01/2026 at 11:30 AM the Assistant Director of Nursing (interim Infection Preventionist) stated when completing a dressing change for tube feeding site and preparing a tube feeding, staff should wear gowns and gloves. Staff should put on the personal protective equipment prior to entering the residents' room and remove the personal protective equipment prior to leaving the residents' room. Gowns and gloves were important to protect the residents and staff from cross contamination of germs. There were signs outside of each precaution room notifying staff of what personal protective equipment was required. Staff were educated on personal protective equipment during orientation, yearly and as needed.10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observations, record review, and interviews (IQIES intake 2799654), the facility failed to ensure a safe, clean, comfortable, and homelike environment for four (4) of seven (7) resident units (Units 2, A, D and C) and one (1) of one (1) resident (Resident #333) reviewed. Specifically, Resident #333 was not provided with a key to a nightstand drawer to secure valuables; Units A and D had clogged, sinks with foul smelling water; Unit C had areas that were unclean and in disrepair: and Unit 2's tub room had an active leak. Findings include:The facility policy Homelike Environment, dated 9/19/2022, documented residents were to be provided with a safe, clean, comfortable, and homelike environment. The residents were to have a facility that had pleasant neutral smells, inviting colors and décor, and cleanliness and order. The1/16/2023 facility admission Agreement documented each resident had a locked drawer in their room for storage of personal property. The facility policy Personal Property, revised 12/17/2025, documented a locked drawer in the resident's room was available as needed if the resident wished to secure personal items or valuables. 1) Resident #333 had diagnoses including anxiety and depression. The 4/21/2026 Minimum Data Set assessment documented the resident was admitted to the facility from the hospital. The comprehensive admission assessment had not yet been completed. The 04/23/26 at 9:22 PM and 9:38 PM Social Worker #22 progress notes documented the resident was met at their bedside and all admission paperwork was signed. The resident was able to make needs known and was admitted for short term rehabilitation. A copy of the residents' rights was provided. During an interview on 04/27/2026 at 4:51 PM, Resident #333 stated they were unable to lock their nightstand drawer as they did have a key. The resident stated they told multiple staff members since they were admitted they would like a key. During an interview and observation on 04/30/2026 at 12:12 PM, Resident #333 stated they still had no key to the nightstand lock. They wanted to ensure certain personal items did not wind up missing and had no way to lock it. A wallet, loose coins, and other personal items were observed in the nightstand top drawer. During an interview on 05/01/2026 at 2:06 PM, the Administrator stated all residents should be offered a key to the locked nightstand upon admission. During an interview on 05/01/2026 at 2:27, Licensed Practical Nurse Manager #5 stated nightstand drawer keys should be offered to each resident on admission. Admitting staff put in a maintenance request to get the key for the resident. They stated they admitted the resident to the facility and the resident refused one at the time. The manager stated they did not enter a note in the resident's record that the resident refused a key. and staff normally did not document the offering of a key. During an interview on 05/01/2026 at 2:59 PM, Registered Nurse Manager #23 stated they had just made aware last night (04/30/2026) that the resident wanted a nightstand drawer key to secure their wallet for safeguarding. The manager stated they then put in a maintenance request for a key. The manager stated that if a resident requested a key to the locked drawer, any staff member was able to enter the work order and then maintenance would bring them a key by the next morning. They did not know why the resident never received a key since admission. 2) During observations on 04/27/2026 at 9:44 AM and 04/30/2026 at 11:21 AM, the hand sanitizer dispenser in the hallway outside of Room C30 was broken. During an observation on 04/27/26 at 09:49 AM, the janitor's closet by Room D13 had a clogged sink with several inches of dark stagnant liquid in the basin with a strong foul odor. During an observation on 04/27/26 at 11:20 AM, the janitor's closet by Room A33 had a clogged sink with several inches of dark stagnant liquid in the basin with a strong foul odor. During an observation on 04/27/2026 at 11:24 AM, the second-floor tub room had an active leak. During an observation on 04/27/2026 at 1:36 PM, Room CS 28 had a large piece of tile (approximately 6 inches in diameter) missing in the room outside the bathroom. During an observation on 04/27/2026 at 2:06 PM, Unit C room [ROOM NUMBER] had dirty linens on the floor including a gown and washcloths. Licensed Practical Nurse #24 walked into the room, left the dirty linen on the floor, and told the resident to put on their oxygen. A certified nurse aide came out of the room and asked another aide where the bags were. The other aide said they could not find any and the unit housekeeper was on break. The dirty linens remained on the floor. During observations on 04/29/2026 at 11:49 AM and 04/30/2026 at 10:13 AM, there was a half piece of tile missing near the Unit C double doors by the bulletin board. During observations on 04/29/2026 at 12:06 PM and 04/30/2026 at 10:26 AM, Room C35-W had brown spots on the ceiling. During an observation on 04/30/2026 at 9:27 AM, the surveyor turned on the call bell for Room C20 and the light did not turn on above the hallway door. During an interview and observation on 04/30/2026 at 9:28 AM Certified Nurse Aide #26 stated if a resident needed something, they should put their call bell on. If a resident could not push the button, they were provided with a tap bell. They were aware Room C20 did not have a functioning call bell. It did not ring, but it would blink over the door. If the call bell did not light up, staff should put in a work order and maintenance would fix it. The aide was not sure if maintenance was notified the bell was not ringing. The aide went into Room C20, pushed the call bell and stated it was lighting up. It just had to be pushed hard. The bell did not alarm at the nurse's station. During an interview on 04/30/2026 at 9:37 AM, Licensed Practical Nurse #24 stated a resident called for assistance by either putting their call bell on or they yelled out. The aide should call the supervisor if the call bell did not work. Room C20's call bell did not ring but lit up. They stated they notified a supervisor about the resident's call bell but did not remember who. The resident called the nurse's station when they needed something. During an interview on 04/30/2026 at 11:18 AM, Licensed Practical Nurse #27 stated linen should not be on the ground for infection control reasons. Work orders for maintenance should be put in if there was a splatter on the wall, or a broken soap dispenser. Maintenance was called directly for emergencies like a toilet overflowing. The nurse went into Room C35 and said the spots on the ceiling were not homelike. At 11:25 AM, the nurse went to soap dispenser, stating it was broken, and could not be used for appropriate hand hygiene. During an interview on 04/30/2026 at 12:05 PM, Certified Nurse Aide #28 stated linen went in a bag and down the laundry chute. There were times when bags for laundry were not readily available and had to be obtained from housekeeping. There was a short supply of bags. Dirty linen should not be on the floor as it was an infection control issue. During an interview on 04/30/2026 at 12:13 PM, Licensed Practical Nurse Manager #5 stated a work order should be put in for normal repairs. Maintenance should be called for emergencies. Triage of the situation was done by maintenance, and normal repairs were completed within 48-72 hours. Hand sanitizer dispenser was used for infection control purposes. It was a tripping hazard and not homelike if floor tiles were missing. The manager stated they had not put in a work order for the dirty ceiling tiles and should have, as it was not homelike in appearance. There should be no linens left on the floor for infection control purposes, and they were also a tripping hazard. During an interview on 04/30/2026 at 1:21 PM, the Director of Maintenance stated any maintenance concerns required a work order to be placed by staff. The director was unaware of the clogged sinks, active leaks, and foul odors that were present in the areas. The director stated the department had not received any work orders for or they would have been fixed. During an interview on 05/01/2026 at 9:37 AM, the Director of Maintenance stated the maintenance department was responsible for maintaining the building and fixing concerns, such as broken soap dispensers, replacing broken tiles, and fixing ceiling splatters. Staff were to put in work orders that were triaged by the department. Urgent issues should be addressed to the department. It usually took less than 24 hours to complete an issue, based on the severity. The department met every day to prioritize work orders. The director did not remember any work orders for the observed conditions. 10 New York Codes, Rules and Regulations 415.29(j)(1)

Based on observations, record review, and interviews, the facility failed to provide routine and emergency dental services to meet the needs of each resident for one (1) of one (1) resident (Resident #296) reviewed. Specifically, Resident #296 was unable to have a dental procedure completed due to their anticoagulant (blood thinner) medication not being held prior to the procedure. Findings include:The facility policy Dental Services, last revised 09/2019, documented both routine and emergency dental services are available to meet the resident's oral health care needs based upon resident assessment and plan of care. Residents have the right to select a dentist of their choice when dental care or services are needed.Resident #296 had diagnoses including pulmonary embolism (blood clot in the lung), anxiety, and depression. The 04/12/2026 Minimum Data Set assessment documented the resident had intact cognition and received an anticoagulant (blood thinner). The comprehensive care plan initiated 07/01/2022, documented the resident was at risk for bleeding secondary to anticoagulant use. Interventions included administering medications as prescribed and monitor for sign and symptoms of abnormal bleeding such as skin bruising and bleeding gums.The 10/31/2025 physician order documented Xarelto (blood thinner) 10 milligrams daily at bedtime for history of pulmonary embolism.The 12/09/2025 Dental Consultation documented the resident presented with missing lower teeth.The 03/21/2026 Dental Consult, initialed by Nurse Practitioner #4 documented trauma to two bottom teeth which needed to be extracted. The 04/15/2026 physician order documented Xarelto 20 milligrams to be discontinued at bedtime. The April 2026 Medication Administration Record documented the following:-on 04/15/2026 at 7 PM- 9 PM, Xarelto was given as ordered. -on 04/16/2026 at 7 PM- 9 PM, Xarelto was not given and a 9 on 04/16/2026 indicating a nursing progress note was written. There was no documented nursing progress note on 04/16/2026. The 04/17/2026 at 4:21 PM, Licensed Practical Nurse Unit Manager #19 progress note documented the interdisciplinary team met regarding Resident #296's 04/17/2026 dental consultation. The updated orders, including the blood thinners, would need to be held for two days prior to procedure which was rescheduled for early next month. During an interview and observation on 04/27/2026 at 10:04 AM, Resident #296 stated they were upset they were supposed to have two teeth extracted, they had the appointment since last month. They were supposed to have medications held and this did not happen. They stated communications within the facility often fell through the cracks. They stated they did not want to be seen with two front teeth missing/cracked. The dentist visited them and said the two broken teeth needed to be removed. When the dental assistant came to get them for the procedure, they informed the dental assistant the facility did not hold their medications. The dentist said they were unable to do the procedure because their medication was not held for three days. During an interview on 04/30/2026 at 10:31 AM, Licensed Practical Unit Manager #19 stated they have an outside contracted dentist. Physician Liaison #36 usually took care of any referrals and appointments. When they got the consultation paperwork from the Physician Liaison, they looked them over and reached out to the Nurse Practitioner #4 to go over them. The nurse practitioner would initial the referral once they put the orders in. Licensed Practical Unit Manager #19 stated they would document a progress note in the Interdisciplinary meetings section which included who the residents saw, who was aware and what type of consultation. If they were to hold blood thinners, this was usually a hold order for three days prior to procedure. They stated the team was aware of the dental procedure coming up. When the dentist said they could not do the procedure, the resident was disappointed. They stated they may have made a mistake with the orders and may have been rushing. They did not have a chance to add the order with dates to hold medication and just put in the order for the day of the dentist's visit. During an interview on 04/30/2026 at 11:44 AM, Nurse Practitioner #4 stated dental was just like any other consultation and any orders must go through the health care provider. They spoke to the dentist, and they said they were going to extract Resident #296's teeth. They gave a verbal order to Licensed Practical Nurse Unit Manager #19 and thought that the resident's blood thinner was on hold. They realized the night before the procedure the medication was not held for the time frame the dentist wanted. There was a miscommunication. 10NYCRR 415.17 (a-d)

Based on record reviews and interviews (IQIES Intake 2801048), the facility failed to ensure all services being provided met professional standards of quality for one (1) of three (3) residents reviewed (Resident #5). Specifically, Resident #5 had an unwitnessed fall on 03/06/2026, was sent to the emergency department for evaluation and was diagnosed with a left proximal humerus fracture (left upper arm broken bone). The facility failed to implement the hospital discharge instructions for the resident's arm fracture, complete a re-admission reassessment, notify the medical provider to update the medical orders for the sling, and update the comprehensive care plan when they returned to the facility on [DATE]. Findings include:The 09/2022 revised facility policy, Admission-Readmission, documented when a resident was admitted /readmitted to a nursing unit, the nurse must complete the Licensed Nurse admission Assessment within the electronic health record. The 05/28/2025 facility policy, Professional Standards of Quality and Practice, documented care and all services were provided according to accepted standards of clinical practice. Resident #5 had diagnoses of malignant neoplasm of the rectum (rectal cancer), muscle wasting and atrophy, and unspecified intellectual disabilities. The 03/11/2026 Minimum Data Set (assessment tool) documented the resident's cognition was not assessed, they required substantial to maximum assistance with toileting, bathing and lower body dressing, partial to moderate assistance with oral hygiene, personal hygiene and transfers from bed/chair to bed, and supervision with walking ten feet. The 03/04/2026 admission Assessment documented Resident #5 had bilateral bruises on their arms, bruising on their abdomen, no history of falls in the past six months and had normal range of motion in their left and right upper extremities.The comprehensive care plan, initiated 03/04/2026, documented that they were at a risk for falls or had an actual fall related to deconditioning. Interventions included: call bell within reach; wear non-skid slipper socks; anticipate needs; physical therapy/occupational therapy evaluation and treat as needed; maintain a clutter-free environment; and toileting assistance as needed and per therapy recommendations. 03/04/2026 Physician's Orders documented acetaminophen (a pain-relieving analgesic) 325 milligrams, take two (2) tablets by mouth every six (6) hours as needed for pain for 10 days. Do not exceed three (3) grams in 24 hours.The 03/06/2026 at 6:30 PM Facility Accident/Incident Investigation Report documented Resident #5 had an unwitnessed fall and was transferred to the hospital emergency department for evaluation of a left forehead hematoma (bruise and bleeding under the skin) and to rule out a left humerus (upper arm) fracture. The following actions were documented as being done after the resident was found on the floor: neurological checks initiated; first aid initiated; call bell in reach with instruction; assisted to standing position; notified on-call medical provider; notified immediate supervisor; notified resident representative; updated the care plan and Kardex; range of motion assessment; skin assessment; placed in bed; and outside services required. The investigation summary documented Resident #5 returned to the facility (03/07/2026) with a fracture to their left upper arm, was given a sling for conservative management, there was no care plan violation, and the resident would be referred to physical and occupational therapy. The Facility Accident/Incident Investigation Report was signed off by the Director of Nursing on 03/18/2026 at 5:33 PM.The 03/06/2026 at 7:14 PM facility Hospital Transfer Form, signed by Registered Nurse Supervisor #3, documented Resident #5 was sent to the hospital for evaluation of a left forehead hematoma and left shoulder pain after a fall. The 03/06/2026 at 7:33 PM Nursing Progress Note by Registered Nurse Supervisor #3 documented Resident #5 had a fall in their room and was found on the floor. They sustained a hematoma on their left forehead, complained of excruciating pain to their left shoulder, and they were unable to perform range of motion. The on-call medical provider was notified. The 03/07/2026 Hospital Emergency Department Summary documented extensive laboratory and diagnostic tests that were performed once the resident was admitted [DATE] through 03/07/2026, to include a computed tomography scan (CT scan) of their head that revealed an intraparenchymal hemorrhage (hematoma) to their left forehead, and an x-ray of their left arm that revealed a left proximal humerus fracture (left upper arm broken bone). There were no interventions necessary for the left forehead hematoma as the resident was stable with normal vital signs. Orthopedic recommendations were: keep left arm sling clean, dry and intact; remove sling intermittently to work on pendulum swing exercises and passive range of motion about the shoulder; elevate extremity; return to emergency department if decreased capillary refill or discoloration of fingers; pain medication per emergency department; non-weight bearing to left upper extremity; and follow up with the orthopedic physician in one week. The resident was discharged from the Hospital Emergency Department 03/07/2026 at 3:19 PM. The 03/07/2026 Nursing Progress Note by Registered Nurse Supervisor #3 documented Resident #5 returned from the hospital at 3:50 PM, and, after meticulous testing at the hospital emergency department, no acute or critical conditions were found. The resident's care was ongoing.There was no documented evidence on 03/07/2026 that a readmission assessment was completed by a registered nurse, a medical provider was notified of the resident's return, or that hospital discharge orders were implemented.Resident #5's 03/07/2026 revised care plan documented limited physical mobility related to weakness. Interventions included: orient to call light/safety measures; engage resident in fall/injury preventions; initiate interventions to prevent skin breakdown/injuries; invite resident to activity programs that encouraged activity/physical activity; and to help with positioning. There was no documentation that the resident had a left fractured humerus that required the use of an arm sling.A 03/07/2026 at 11:33 PM Nursing Progress Note by Licensed Practical Nurse #13 documented the resident complained of pain and was resting in their bed with their eyes closed at that time.There was no documented evidence pain medication administered on evening shift of 03/07/2026 related to License Practical Nurse #13's 03/07/2026 at 11:33 PM Nursing Progress Note.A 03/11/2026 Physical Therapy note documented the resident had minimal progress, had multiple falls and had declined therapy treatment. They were discharged from therapy 03/10/2026.During an interview on 03/20/2026 at 10:43 AM, Registered Nurse Supervisor #3 stated they recalled the resident returning from the hospital (03/07/2026) with a sling on their left arm. They reviewed the hospital paperwork but did not see and was not aware the resident had a fracture to their left arm. The hospital paperwork only addressed the resident's rectal cancer diagnosis (which was already known to the facility).During an interview on 03/20/2026 at 3:15 PM, Certified Nurse Aide #4 stated they cared for Resident #5 after they returned from the hospital (03/07/2026). The emergency medical technicians handed them paperwork for the nursing supervisor, and they placed it on the desk at the nurse's station. Resident #5 had a black-colored sling on their left arm when they returned. Resident #5 would occasionally take the sling off. The resident was able to communicate and make requests but did not verbalize pain. They were not informed of how to care for the resident's sling or that the resident had a fracture to their left arm.During an interview on 03/20/2026 at 12:25 PM, Nurse Practitioner #8 stated they had no knowledge of Resident #5's fracture to their left arm and would have expected a medical provider to be notified when they returned from the emergency department 03/07/2026. It was important to call the hospital to obtain the hospital after-visit summary to see what treatment was given and what care was needed upon return. They would never re-admit a resident without having the proper documentation. Registered Nurse Supervisor #3 did not do a re-assessment, notify a medical provider or obtain an order for the resident's sling. A sling would have required a physician's order. Direct care staff would have needed to know how to care for the resident with their fractured left arm, especially for transfers. During an interview on 03/23/2026 at 11:49 AM, Physician #9 stated they were not aware of Resident #5's left humerus fracture after their fall on 03/06/2026 and subsequent transfer to the emergency department (the on-call medical provider was notified 03/06/2026 and it was not Physician #9). It was important to phone the hospital and find out what evaluations were completed and what treatments were implemented, including imaging, as it would change the resident's plan of care. If staff had no knowledge of a fracture, it could cause further harm to the resident. The resident's Physician's Orders showed acetaminophen as needed for pain (start date of 03/04/2026), but the resident did not receive any from 03/04/2026 to 03/11/2026. During an interview on 03/23/2026 at 1:00 PM, Physical Therapist #14 stated Resident #5 required contact guard assistance with their activities of daily living. When the resident was receiving therapy on 03/10/2026 they observed the resident's left arm, which was black and blue from the shoulder down to the elbow. The resident was attempting to use their walker and they could not raise their left arm. The resident verbalized that it hurt. They reported that information to the 4 North Unit nurse (they could not recall the nurse's name). They had not been informed Resident #5 had a left arm fracture. If they had known Resident #5 had a fracture to their left arm it would have changed their plan of care. During an interview on 03/23/2026 at 1:15 PM, Occupational Therapist #15 stated they heard Resident #5 fell and went to the hospital (03/06/2026). They were unaware the resident had a fracture to their left arm, and if they had known, they would not have used the resident's left arm until an order from an orthopedic physician was obtained. During a follow-up interview on 03/23/2026 at 03:06 PM, Registered Nurse Supervisor #3 stated when a resident returned from the hospital less than 24 hours later, they did not always return with after-visit summary discharge paperwork. They recalled Resident #5 having paperwork and remembered seeing a sling. They were not aware of the fracture, did not phone a physician or obtain orders for the sling. During an interview on 03/23/2026 at 4:30 PM with the Administrator, they stated the Interdisciplinary Team discussed every nursing unit in morning report regarding residents' changes in condition, room changes, facility census and resident consultation reviews. They were not aware of Resident #5's left arm fracture. The hospital discharge paperwork was printed by the facility on 03/10/2026. The facility investigation into Resident #5's fall on 03/06/2026 was started by Registered Nurse Supervisor #3 and it was signed off by the Director of Nursing on 03/18/2026. During a phone interview on 04/01/2026 at 12:40 PM, Licensed Practical Nurse #21 stated they remembered putting the left arm sling on Resident #5 on several occasions and adjusting it when the resident tried to remove it, but they did not know why the resident had a sling. They were unaware the resident had a left fractured humerus (after being told during the phone interview). The resident's left arm sling would have been in the Treatment Administration Record (it was not). They could not remember for certain if staff from therapy approached them about the resident not having range of motion in their left arm and that it should be evaluated for a possible fracture, but they may have. They would have notified their supervisor about therapy's concerns. They did recall the resident fell frequently. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews during the recertification survey conducted 5/12/2025 - 5/16/2025, the facility did not ensure the environment accommodated residents' needs for two (2) of two (2) residents (Residents #7 and #122) reviewed. Specifically, Residents #7 and #122 did not have their call bells within reach. Findings include: The facility policy, Call Light System - Resident Response, created 12/2017, documented call lights were to be plugged in at all times and were within easy reach of the resident. 1) Resident #122 had diagnoses including stroke affecting the right dominant side of the body, reduced mobility, and major depressive disorder. The 2/17/2025 Minimum Data Set assessment documented the resident was cognitively intact and required substantial/maximum assistance for most activities of daily living. The Comprehensive Care Plan initiated 2/10/2025, documented the resident was at risk for falls and required assistance with self-care and mobility related to hemiplegia (paralysis or weakness on one side of the body). Interventions included the call bell should be within reach and encourage the resident to use the call bell to call for assistance. During an observation on 5/12/2025 at 11:08 AM, Resident #122 was lying in bed, their call bell was on the floor at the foot of the bed. They stated they never had their call bell and staff ignored them. Certified Nurse Aide #11 entered the room, dropped off food, left the room and returned a few minutes later with ice water. Certified Nurse Aide #11 did not pick up the call bell from the floor. 2) Resident #7 had diagnoses including schizophrenia (a mental disorder with symptoms including delusions, hallucinations, and difficulty thinking), fibromyalgia (widespread body pain), and major depressive disorder. The 5/5/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment and was dependent for most activities of daily living. The Comprehensive Care Plan initiated 10/29/2024 and revised 5/1/2025 documented the resident had an actual fall and remained at risk for falls related to decreased mobility, poor safety awareness, and schizophrenia. Interventions included ensure the call bell was always within reach and the resident was encouraged to use it for assistance. The following observations were made of Resident #7: - on 5/12/2025 at 10:10 AM, lying in bed, their call bell was on a bag at the foot of their bed. - on 5/13/2025 at 8:53 AM, their call bell was rolled up and in a bag of clothing placed on top of a nightstand several inches away from the foot of the bed. During an interview on 5/14/2025 at 2:27 PM, Certified Nurse Aide #11 stated call bells should be attached to the resident or clipped to the pillow or blanket if the resident was in bed, and they should be within reach. Resident #122 had weakness on one side. They knew how to use the call bell, but they never used it. Resident #7 rang the bell if they needed something. If a resident needed something and the call bell was out of reach, there were safety concerns like trying to get out of bed and falling. During an interview on 5/15/2025 at 1:15 PM, Licensed Practical Nurse #23 stated residents should have their call bells within reach so they could call for help when needed. The call bell should never be on the floor or under the bed, as it was a safety concern. If they saw call bells on the floor, they picked them up and placed them within reach of the resident. Resident #7 and Resident #122 should have their call bell within reach. During an interview on 5/15/2025 at 1:38 PM, Licensed Practical Nurse Unit Manager #12 stated call bells should be within reach as they were the resident's lifeline. If staff saw a call bell out of reach, they should place it within reach of the resident. It would be a safety concern if the call bell was not within reach of the resident. During an interview on 5/16/2025 at 11:24 AM, Assistant Director of Nursing #3 stated call bells should be within reach so residents could call for help. If call bells were not within reach, resident concerns such as respiratory distress, being soiled, or needing pain medication may not be addressed. 10 NYCRR 415.5(e)(1)

Based on observation, interview, and record review during the extended recertification and abbreviated (NY0033160) surveys conducted 6/4/2024-7/11/2024, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 5 of 5 residents (Resident #41, #126, #153, #235, and #250) reviewed. Specifically: - Resident #41 had an extensive mental health history, did not have person-centered mental health interventions, and was seen by a licensed psychologist and their recommendations were not implemented into the resident's plan of care. There were no documented social services follow ups with the resident following their behaviors. - Resident #126 had a significant mental health history and did not have person-centered mental health interventions for their behaviors or refusals of care and medications. There were no documented social services follow ups with the resident following their behaviors. - Resident #153 was seen by a licensed psychologist and their recommendations were not implemented into the resident's plan of care, a recommendation for a traumatic brain injury program was not investigated, and recommendations to continue psychotherapy were not followed. There were no documented social services follow ups with the resident following their behaviors. - Resident #235 had behaviors of taking things off the nurses' cart and throwing them leading up to an episode of threatening staff with scissors, requiring police intervention and hospitalization for the resident. There were no documented interventions from social services and the resident did not have person-centered interventions for their history of delusions and taking/throwing things off the nurses' cart. - Resident #250 had an extensive mental health history including paranoid schizophrenia and did not have person-centered mental health interventions for their behavioral symptoms. This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care. Findings Included: The facility policy, Behavior Management revised 5/2020, documented the facility provided an interdisciplinary approach for the care of residents who exhibited problem behavioral symptoms which could lead to negative consequences for themselves or others. Residents who demonstrated changes in behavior would be evaluated to ensure appropriate interventions, as needed, were instituted in a timely manner. A resident's behavioral symptoms and approaches would be placed in the resident-specific plan of care and communicated to care staff and other departments as appropriate. The facility policy, Care Plans- Comprehensive revised 10/2019, documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The identification of problem areas and their causes and developing interventions that were targeted and meaningful to the resident, was the goal of the interdisciplinary process. The interdisciplinary team reviewed and updated the care plan quarterly, when a significant change occurred, when a desired outcome was not met, and when a resident was readmitted from a hospital stay. The facility policy, Social Services revised 10/2019, documented the facility provided medically related social services to assure each resident can attain or maintain their practicable physical, mental, or psychosocial well-being. 1) Resident #41 had diagnoses including schizoaffective disorder (a mental health condition with a mix of schizophrenia symptoms and mood disorder symptoms), anxiety, and depression. The 4/27/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident had severely impaired cognition, had no behavioral symptoms in the 7-day look back period, was independent with most activities of daily living, had a diagnosis of schizophrenia disorder (schizoaffective and schizophreniform disorders), anxiety, and depression and was taking an antidepressant and an antipsychotic medication daily. The 4/29/2024 Comprehensive Care Plan documented the resident utilized psychotropic medication related to schizoaffective disorder, anxiety, and depression with hallucinations and psychosis. Interventions included to give medications as ordered, monitor and record target behaviors and potential side effects, and have psychiatry and psychology consults as needed. There were no documented person-centered interventions. A 1/7/2024 at 1:03 PM Licensed Practical Nurse #66's progress note documented the resident told them they were leaving. They notified the Supervisor who came to the unit and spoke to the resident. The Supervisor told Licensed Practical Nurse #66 if the resident attempted to leave to not attempt to stop them and let the Supervisor know. At 12:52 PM the resident came into the main hallway with two garbage bags full of items and started walking toward the elevator. The Supervisor was called. The resident got on the elevator and the doors closed. A 1/7/2024 at 2:00 PM Registered Nurse Supervisor #19's progress note documented the resident cut off their wander alert device and took the elevator to leave the facility. Emergency Medical Services and the police department was called due to the resident's attempt at an unsafe discharge. The resident's Health Care Proxy was called and agreed to transfer the resident to the hospital. The resident was sent to the hospital for psychiatric evaluation. The 1/7/2024 hospital after visit summary documented the resident was seen for a mental health problem with a diagnosis of difficulty controlling their anger. General information on managing anger was provided in the form of a paper hand out with directions to go to the comprehensive psychiatric emergency program if symptoms worsened. The 1/9/2024 Licensed Psychologist #36 progress note documented the resident had depression, schizoaffective disorder, and adjustment disorder. The resident felt angry, defiant, frustrated, and overwhelmed. The resident stated they had been taken to the hospital for crisis management and was angry with the interaction. They had difficulty with reality testing during the session and stated they would live in the woods with the animals like they had in the past when they had been raised by bears. The resident stated they would commit suicide by cop if they were engaged by law enforcement again to be forced to go to the hospital. The Registered Nurse Manager and nurse practitioner were informed of the statement and to be aware of the intention of aggression if confronted by law enforcement. The facility nurse practitioner was looking to coordinate a transfer to a more intense psychiatric program. The plan included to continue with psychotherapy and to follow up with therapy as scheduled. The recommendation was to continue with supportive care, safety precautions per facility policy, monitoring for mood, behavior, and sleep, redirect as clinically indicated, and to continue with psychotherapy. The resident remained with altered mental status and psychosis and had been highly agitated. Approach the resident with empathy and nonthreatening language and behavior. An escalation of conflict would result in a negative outcome and the resident should be provided with space, a soft voice, and a nonthreatening tone. There was no documented evidence the resident's Comprehensive Care Plan was updated to include the recommendations from Licensed Psychologist #36. The 1/18/2024 Licensed Psychologist #36 progress note documented the resident was angry, blaming, and edgy/irritable. The resident was angry and felt trapped in the facility. This triggered the resident's history of being abused and resulted in aggressive behavior for self-defense and survival. The resident was provided with reflective listening, disarming, and thought/feeling empathy and the resident was agitated but responsive. The recommendation was the same as the 1/9/2024 psychotherapy progress note. There was no documented evidence the resident's Comprehensive Care Plan was updated to include the recommendations from Licensed Psychologist #36. The 1/29/2024 Chief Medical Officer #11's progress note documented the resident had removed their wander alert device over the weekend and was brought back by police. The resident was actively threatening to kill themselves without a specific plan. They were also threatening to harm other individuals but did not state who the intent was directed at. The licensed psychologist was present during the visit. The resident had not been taking their antipsychotic medication. The resident was sitting in their chair physically shaking their hands which appeared to be extremely aggressive movements. The resident was threatening to harm themself and everyone around them. 911 was notified with police back up. The resident was deemed a risk to themselves and other residents in the facility. After much discussion they were able to get the resident to voluntarily go to the hospital. The 1/29/2024 hospital after visit summary documented the resident had been seen for homicidal, suicidal, and aggressive behavior with diagnoses of suicidal thoughts and aggressive behavior. The resident had been cleared by psychiatry prior to discharge with a recommendation to follow-up with outpatient providers as necessary. There was no documented evidence the comprehensive care plan was revised to reflect suicidal and homicidal ideations. A 2/10/2024 at 12:00 PM Licensed Practical Nurse #31's progress note documented the resident was threatening staff stating if a certain nurse was not there to help them, the resident would harm the staff. The resident began swinging at the staff providing 1:1. A 3/20/2024 Licensed Psychologist #36 progress note documented the resident was angry, and ranted and vented their dislike and distrust. The did not want to be in long term care. The resident seemed interested in treatment, was motivated, shared appropriate thought process and seemed to benefit from the session. Recommendations included continue psychotherapy as scheduled, supportive care, safety precautions, monitoring mood/behavior/sleep, and redirect as clinically indicated. Those approaching the resident should use empathy and non-threatening language and behavior. Escalation of conflict would result in negative outcomes. The resident would be seen by the clinician in 1-2 weeks. There was no documented evidence of follow-up in 1-2 weeks by Licensed Psychologist #36 after the 3/20/2024 consultation. The 6/4/2024 comprehensive care plan documented the resident had behavioral symptoms such as refusals of medications for auditory and visual hallucinations. Interventions included to determine the cause and maintain the resident's safety, initiate psychiatric and psychology evaluation as needed, praise and reinforce appropriate behavior, and for certified nurse aides to monitor behavior symptoms as needed. There was no documentation of what interventions to implement when behavioral symptoms occurred or of the resident's history of homicidal and suicidal ideations, aggressive behavior, or history/verbal statements of planned combativeness when law enforcement was called. During an interview on 6/11/2024 at 11:15 AM, Social Worker #37 stated social work was responsible for the care plans that involved mental health and behavioral symptoms. Care plans were updated quarterly, for a significant change, and as needed when issues came up. If a resident had specific behaviors, they should be included in the plan of care. If a resident was on psychotropic medications, their behaviors would be in the interventions on the care plan. If a resident exhibited their target behaviors, staff should report those behaviors to the physician, see if there were any as needed medication that could be given, and contact the psychologist or psychiatrist. They did not list immediate specific interventions for staff to implement when a behavior occurred, but they should as the care plan was meant to be person-centered. Resident #41's behaviors were not care planned with specific interventions but should have been. There should be a care plan for a resident who had homicidal and suicidal ideations. They stated they were not aware Resident #41 had a history of homicidal and suicidal ideations. During an interview on 6/11/2024 at 11:59 AM, the Director of Social Work stated residents' behaviors should be documented on their plan of care. The resident should also have specific interventions for their behaviors. What worked for one resident may not work for another. The staff would know what interventions to implement for the resident by looking at their plan of care. If a resident had a history of suicidal ideations and homicidal ideations it should be on the plan of care. During an interview on 6/12/2024 at 10:20 AM, Resident #41 stated they did not like doing mental health appointments over the phone or via telehealth. They stated they did not like to talk to a screen so would refuse if that was offered. They stated they did participate with Licensed Psychologist #36 because they came in person to talk to them. The resident stated they had a history with their mental health which included mental health inpatient stays related to messing up their medications and being involved with a treatment team when they were living in the community. During an interview on 6/12/2024 at 10:33 AM, Licensed Psychologist #36 stated they had seen Resident #41 in May 2024 and June 2024 but there was a period where the resident was avoiding visits by pretending to sleep. When the resident started to become more involved in physical therapy and going out with their adult child, so they were unable to see them. They expected their recommendations for approaches and interventions for behaviors to be included in the resident's plan of care. They stated the resident's verbalization about committing suicide by cop and the need to let law enforcement knows the resident would react aggressively to law enforcement should be on their plan of care so that someone not familiar with the resident would be aware should the police need to be called. During an interview on 6/12/2024 at 12:26 PM, Nurse Practitioner #22 stated the resident had exacerbations of their schizoaffective disorder with psychotic features where they were aggressive towards staff and threatened to harm themself. They sent the resident to the hospital multiple times for being a danger to themself and others. When the resident got bad, they could not be controlled in this setting and had to be sent out. Recently, the resident's behaviors had been controlled but the resident had a history of ups and downs. Any behavioral approach recommendation from Licensed Psychologist #36 should be on the resident's plan of care. They stated specific non-pharmacological interventions for behaviors should be on the plan of care. During an interview on 6/12/2024 at 12:46 PM, Chief Medical Officer #11 stated if Licensed Psychologist #36 made any recommendations for behavioral health they needed to be known by the resident's direct care staff and should be on the care plan. 2) Resident #153 had diagnoses including intracranial injury with loss of consciousness (brain injury), major depressive disorder, hydrocephalus (fluid buildup in the brain that causes brain swelling), and vascular dementia. The 5/17/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had verbal behavioral symptoms directed towards, rejected care, and wandered 1-3 of 7 days, was independent with activities of daily living, and took antipsychotic and antidepressant medication routinely. The 3/2/2023 physician order documented to monitor for behaviors: itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusion, hallucinations, psychosis, aggression, and refusing care. The comprehensive care plan initiated 5/3/2022 documented the resident exhibited behavior of wandering through out the unit taking items off the nurses' station desk, taking staff and resident food from fridge, entering other residents' rooms, and taking personal items belonging to others, episodes of socially inappropriate behaviors, and episodes of verbally aggressive behavior. The interventions were to check for thirst and hunger, distract resident with preferred activity, initiate psychiatric and psychology evaluation as needed, modify the environment to reduce episodes of behavior, and to redirect negative behavior as needed. The Psychiatric Mental Health Nurse Practitioner #91 recommended the resident would benefit from talk therapy. The 3/20/2024 Licensed Psychologist #36 progress note documented the resident had been aggressive to staff as well as peers. The recommendations included to continue supportive care, continue with safety precautions per facility protocol, continue monitoring for mood, behavior, and sleep, to redirect as clinically indicated, and to continue with psychotherapy. The resident would be provided with psychotherapy 1-3 times per month to assist with monitoring of mood and behavior. The goal was to work to reduce aggressive behavior, improve coping skills for boredom, work on acceptance of circumstances, and increase prosocial skills. The resident would benefit from the investigation of a traumatic brain injury program that allows for more activity and behavioral support, possible community-based integration with supervision. There was no documented evidence a traumatic brain injury program was explored as recommended. The resident had no documented psychotherapy notes after 3/20/2024. The 6/11/2024 Psychiatric Mental Health Nurse Practitioner #73 documented the resident had increased wandering at night, intermittent medication refusals, and verbal aggression toward staff. There was no documented evidence of social work progress notes related to the resident's behaviors or increased wandering. During an observation on 6/24/2024 at 4:44 PM The resident was standing up and was acting verbally aggressive toward the nurse. The resident stated, I am going to go in everyone room, grab hold of them. The nurse was documenting on a computer and the resident pointed toward the surveyor and said, she don't know me, thinks I am a sucker. The June 2024 treatment administration record documented monitor for behaviors: itching, picking at skin, restlessness, hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusion, hallucinations, psychosis, aggression, and refusing care. Document Y if monitored and none of the above were observed. Document N if monitored and any of the above was observed, and document in progress notes as Behavior note every shift. The behaviors had documented check marks with no Y or N from 6/1/2024-6/26/2024 (12 of 78 opportunities for documentation were blank). Nursing notes from 6/1/2024-6/26/2024 documented: - 6/4/2024 at 12:42 by Licensed Practical Nurse #34 PM refused all meds. - 6/9/2024 at 2:18 PM by Licensed Practical Nurse #98, the resident refused medications after three attempts and stated. I ain't takin' that [expletive], why you standin' there watching me, like I won't knock you out. Continued to approach staff and residents stating, I've been fighting my whole life, I'll knock your ass out. Redirection was unsuccessful. - 6/11/2024 at 3:50 AM by Licensed Practical Nurse #99 resident found standing next to another resident's bed looking at them, redirection was attempted, and the resident became verbally abusive when redirected. - 6/11/2024 at 4:55 AM by Registered Nurse Supervisor #89 aware of resident entering another resident's room. Reminded staff to complete behavior notes. - 6/17/2024 at 1:17 PM by Licensed Practical Nurse #98 attempted to administer medications three times. Resident refused stating they were tired of this [expletive]. - 6/20/2024 at 1:00 PM by Registered Nurse Unit Manager #94 refused medication after numerous attempts. Resident then went outside with a certified nurse aide. - 6/24/2024 at 12:07 PM by Licensed Practical Nurse #98 Resident held medications in their hands for 30 minutes before placing them in their mouth. Resident continuously stated, I've been fighting my whole life, I'll [expletive] your ass up. The resident held the medications in their mouth for 30 minutes before swallowing. There was no documented evidence the social worker or physician was aware of the resident's behavioral symptoms in 6/2024. During an observation on 6/26/24 at 10:03 AM, the resident was in their room sitting on the edge of bed, dressed, no sneakers on, wrapped in a sheet, wiggling their right leg, and twisting the sheet. During an interview on 6/27/2024 at 11:06 AM, Licensed Psychologist #36 stated they saw the resident on 4/11/2024 in addition to their initial visit on 3/20/2024. They stated the recommendations from their psychotherapy note included a traumatic brain injury program that allowed for more activity and behavioral support for the resident as well as possible community integration. The resident had hydrocephaly and when the shunt became blocked, the resident's behavior could change significantly. The resident would benefit from the traumatic brain injury program as it would be more specialized care and would assist with behavior management. The resident was young, bored, and was triggered easily. The resident felt very trapped but also cognitively lacked clarity and did not understand their processes. During an interview 6/26/2024 1:35 PM, the Director of Social Work stated they reviewed Licensed Psychologist #36's notes after they were completed, and they also received a synopsis of the visits via email from the provider. They were unaware if the resident had been seen since the initial visit in March 2024. They did not think the recommendation for a traumatic brain injury program was followed up on. The social workers should meet with residents who are having behaviors or increased behaviors. During an interview on 6/27/2024 at 2:36 PM, Nurse Practitioner #22 stated the resident's behaviors were related to their traumatic brain injury and hydrocephaly; especially if the shunt for their hydrocephaly was blocked. The resident's nature was if you said hello to them, they would respond with I'm going to punch you. They did not believe the resident to be an immediate threat, but they had the potential. They had to move the resident depending on the nature of the patient population of the floor the resident was on. They did believe the recommendation for a traumatic brain injury program to assist with boredom and behaviors would be good for the resident due to need for more specialized care. A community outpatient program could be beneficial to assist the resident. They believed the resident needed more than they were getting in the facility. 3) Resident #235 had diagnoses including unspecified dementia without behavioral disturbance and major depressive disorder. The 3/28/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition with disorganized thinking and inattention, had mild depression, had a diagnosis of non-Alzheimer's dementia and depression, and received antipsychotic and antidepressant medication routinely. The comprehensive care plan initiated 4/1/2023 documented the resident had a potential for resident-to-resident altercation as evidenced by aggression, hitting, slapping, throwing objects, yelling, and using foul language. Interventions included administer medications, identify environmental triggers, maintain visual line of sight, monitor behavior and document, notify medical doctor of negative behavior, offer diversional activity, refer to psychiatry/psychology services, and separate from the aggressor/victim. The resident exhibited behavior symptoms such as aggressiveness and danger to other due to cognitive impairment. 2/18/204, the resident attempted to stab at staff with sharp scissors. Additional interventions included to send the resident to the hospital for psychological and medication evaluation due aggressiveness, attempt to hurt others, brandishing a weapon (scissors), and danger to self and others. Nursing notes documented: - on 2/13/2024 at 3:16 PM by Licensed Practical Nurse #86 the resident was extremely agitated and confused and repeatedly threw items from the nursing cart and screamed for the State Police to be called. The resident was difficult to redirect. The Supervisor and Unit Manager were notified. - on 2/18/2024 at 7:49 PM by Registered Nurse #18 the licensed practical nurse reported the resident was extremely agitated and confused and repeatedly threw items from the nursing cart and called for the State Police to be called. Telemedicine was called and an order for Haldol (antipsychotic) 5 milligrams/milliliter inject intramuscularly one time only for aggressive behavior. Obtain a stat (immediate) urinalysis for possible urinary tract infection. - on 2/19/2024 at 2:20 AM by Registered Nurse Unit Manager #23 the resident was threatening staff with a pair of scissors and lunged at staff in a threatening manner. They attempted to retrieve the scissors and the resident tried to swipe at all staff who attempted. Resident was making delusional statements, was offered, and refused oral Haldol stating there was arsenic in it. Emergency Medical Services was called. Staff was told to stay away from the resident for safety, police arrived and requested the scissors, and the resident threw the scissors at the officer and the scissors landed on the floor. The resident was sent out of the facility for psychiatric evaluation. The 2/19/2024 hospital after visit summary documented the resident was seen for a psychiatric evaluation, had a diagnosis of dementia with behavioral disturbance, and was provided with an antipsychotic at the hospital. The 2/21/24 initial psychiatric evaluation by Psychiatric Mental Health Nurse Practitioner #73 documented the resident had an incident on 2/19/2024 when the resident was threatening staff with a sharp pair of scissors and trying to lunge at staff. They also had increased paranoia and refusing medications due to the belief they had arsenic. There was a concern the resident was not taking their medications and was spitting them out which the resident's adult child stated they had a history of. They recommended to decrease the environmental stimuli, ensure all needs were met, and implement behavior interventions such as distraction measures. There was no documented evidence the care plan was updated with the recommendations from the Psychiatric Mental Health Nurse Practitioner #73. There were no nursing progress notes on 3/31/2024 documenting the resident had behaviors or was sent to the hospital. The 3/31/2024 hospital after visit summary documented the resident was seen for aggressive behavior, had a diagnosis of dementia of unspecified type whether behavioral, psychotic, or mood disturbance, or anxiety, and was provided with psychotropic medication at the hospital. There were no documented social services progress notes in relation to the resident's increased behaviors or emergency department visits for psychiatric evaluation or aggressive behavior. During an interview on 6/26/2024 at 11:40 AM, Social Worker #92 stated the social worker's role if a resident was having behaviors was to try to find interventions for the resident and put them in their plan of care. The plan of care identified the resident's behaviors and the interventions to meet the stated goal. The plan of care should be personalized for each resident. Any interaction with the resident should be documented. If a resident had a change in condition or increased behaviors, they would make a referral for either psychiatry or psychology. If they noticed a change, they would speak with nursing to see if the change was new or if a referral had gone in. They believed Resident #235 had a personalized plan of care. The resident's history of throwing things off the nurse's medication cart, spitting out their medications, or delusions of believing their medication contained arsenic was not included on the resident's plan of care. If a resident's behaviors were resolved, they should be removed from the plan of care. They did not include the resident's history of behaviors on their plan of care. During an interview on 6/26/2024 at 1:35 PM, the Director of Social Work stated if a resident went to the emergency department for psychiatric reasons, the social worker should check on them when they returned. Care plans were not only for active behaviors. If someone has not had a behavior in a while, the care plan could be changed to state a history of so the information was not completely gone and there was a trail. During a follow up interview on 7/02/2024 at 1:24 PM, they stated an intervention that documented to provide distraction measures was not personalized as it should include what the distractions were. During an interview on 6/27/2024 at 2:36 PM, Licensed Psychologist #36 stated they had seen the resident and was unsure why their psychotherapy notes were not in the electronic medical record. They stated the resident was referred for psychotherapy services after their emergency department visits in February 2024 and March 2024 for mental health. Their recommendation was to monitor the resident and continue supportive care as their dementia was progressing. The resident's family visited, and the resident did well with that. The resident really enjoyed visiting and was easily redirected. 10 NYCRR 483.40 (d) ________________________________________________________________ Immediate Jeopardy was identified, and the Administrator was notified on 6/27/2024 at 4:00 PM. Immediate Jeopardy was removed on 7/03/2024 at 11:43 AM prior to survey exit based on the following corrective actions taken. -100% of social work department staff had been educated on medically related social services. -Post-tests were reviewed. -Staff education sign in sheets were reviewed and compared to the current social work staff list and no discrepancies were identified. -Staff education was verified during an onsite visit on 7/1/2024, all social work department staff were interviewed to determine retention of education provided and were able to accurately report content of the education. -All five identified residents resident records were reviewed, and documentation reflected each had a social work assessment completed. -All five identified resident plans of care were reviewed and had updated person-centered interventions for their mental health.

Based on record review and interview during the extended recertification and abbreviated (NY00335379) surveys conducted 6/4/2024-7/11/2024, the facility failed to ensure the ordering physician was notified promptly when a laboratory result fell outside of clinical reference range for 3 of 3 residents (Residents #153, #260, and #529) reviewed. Specifically, - Resident #529 had abnormal laboratory results including a high white blood cell count, a low lymphocyte count, and high sodium, blood urea nitrogen, and blood urea nitrogen/creatinine ratio (indicating possible dehydration and infection) that were not reviewed by facility staff in a timely manner, and the medical provider was not notified in a timely manner of the abnormal lab results. Subsequently, the resident was hospitalized 3 days later with pneumonia and dehydration. - Resident #153 had a critically low blood glucose (blood sugar) of 49 milligrams/deciliter and the provider was not notified in a timely manner and the resident was not assessed. - Resident #260 had a high international normalized ratio (INR, used to determine blood clotting times for residents on anticoagulant therapy) and the provider was not notified timely, and the resident was not assessed. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety. Findings include: The facility policy, Laboratory Services, revised 8/2019, documented the facility would provide or obtain laboratory services to meet the needs of its residents. Licensed staff would make appointments and arrangements with the facility's laboratory for all the resident's ordered laboratory tests, obtain specimens as needed, and promptly inform the resident's physician of all abnormal test results by phone or fax. When the physician responded, the response was to be documented in the resident's chart. The facility policy, Anticoagulation Therapy, revised 3/2019, documented all residents would have labs drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. The physician would order appropriate lab testing to monitor anticoagulant therapy. Staff could use a warfarin flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response. The policy did not include directions for communication of lab testing results to the physician. The electronic medical record Lab Results report documented a legend for flags included on the report. A red stop sign with an exclamation mark in the center indicated the report contained critical results (results in red text). A yellow triangle with an exclamation mark in the center indicated the report contained abnormal results (results with orange text). 1) Resident #529 had diagnoses including dementia, malnutrition, and peripheral vascular disease (poor circulation). The 1/26/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident had severely impaired cognition, was dependent with most activities of daily living, had 1 venous/arterial ulcer, and was on a mechanically altered diet. A 10/5/2023 Registered Dietitian #14 progress note documented the resident's estimated fluid requirements were 1480-1725 cubic centimeters per day. The 11/16/2023 Comprehensive Care Plan documented the resident had an actual/potential fluid deficit related to dehydration, was at risk of aspiration (inhaling food or fluid into the lungs) and had actual skin impairment related to an arterial wound on the left foot. Interventions included ensure resident had access to nectar/mildly thickened juice/water whenever possible; keep in an upright position while eating; blood urea nitrogen and creatinine laboratory tests per physician orders (potential indicators of dehydration); and monitor, document, and report to nurse signs/symptoms of fluid deficit including decreased or no urine output, concentrated urine, new onset confusion, increased pulse, and dizziness. The 1/18/2024 physician orders documented a complete blood count (blood test that measures the number and characteristics of blood cells) and a comprehensive metabolic panel (blood test that measures chemical balance and metabolism) every month. The 1/29/2024 Nutritional Assessment completed by Registered Dietitian #14 documented the resident was on a pureed consistency with nectar thick liquid and was dependent with eating. Their overall fluid intake was 1501-1800 cubic centimeters a day (did not document the period for the average fluid intake). The resident did not refuse fluids. The 2/2024 Certified Nurse Aide Survey Report documented the resident consumed 0-300 cubic centimeters of fluid daily between from 2/10/2024-2/17/2024. There was no documented evidence the resident's poor fluid intake was reported to the medical provider. The facility lab results report documented a lab specimen was collected on 2/15/2024 at 10:15 AM for a compete blood count and a comprehensive metabolic panel. The lab reported results to the facility on [DATE] at 2:00 PM . The lab results were flagged with a yellow triangle to indicate there were abnormal results. The results for the complete blood count and comprehensive metabolic panel laboratory report included the following abnormal laboratory values (in orange text): - high white blood cell count (potential indicator of infection) 13.3 units per microliter (normal 4.1-11.0 per microliter); - low lymphocyte % (potential indicator of infection) 5.8% (normal 16-52%); - high neutrophils % (potential indicator of infection) 86% (normal 35-75%); - high sodium (electrolyte, potential indicator of dehydration) 149 millimoles per liter (normal 136-145 millimoles per liter); - high blood urea nitrogen (potential indicator of dehydration) 35 milligrams/deciliter (normal 9-23 milligrams/deciliter); - high blood urea nitrogen/creatinine ratio (potential indicator of dehydration) 53.8 (normal 10-20). The bottom of the report had a space to sign and date when the results were reviewed. There was no documentation the results were reviewed on the day they were received. From 2/15/2024 to 2/17/2024, there were no documented nursing or provider notes in the resident's record regarding changes in the resident's condition. The 2/18/2024 at 1:37 PM Registered Nurse #18 progress note documented they were notified by the licensed practical nurse the resident had abnormal vital signs. The resident was assessed and found with signs of lethargy and symptoms of change in condition including a high heart rate of 152 beats per minute (normal 60-100 beats per minute) and oxygen saturation (level of oxygen in the blood) of 70% (normal level 95-100%) on room air. Oxygen was immediately administered at 5 liters per minutes with oxygen saturation increasing to 95%. The on-call provider was notified and agreed to transfer the resident to the hospital for further evaluation. The progress note did not document if Registered Nurse #18 was aware of the 2/15/2024 laboratory results or had reported the results to the on-call provider. The 2/18/2024 hospital report documented the resident presented from the facility for generalized weakness and was admitted with sepsis (life threatening complication of infection), acute respiratory failure, and severe hypovolemic (low fluid portion of blood) hypernatremia (high sodium). The resident's white blood cell count was high at 19 units per microliter and their sodium was high at 161 millimoles per liter. The resident was admitted to the intensive care unit and started on antibiotics and intravenous fluids, along with systemic steroids (medication to reduce inflammation) for severe pneumonia. The 2/15/2024 laboratory results document was electronically signed by facility Nurse Practitioner #16 on 2/22/2024 at 2:49 PM, 4 days after the resident was transferred to the hospital. During a telephone interview on 6/7/2024 at 10:24 AM, Licensed Practical Nurse Manager #13 stated every unit had a lab day and the providers followed up to review results daily. Lab values populated to all nursing and provider dashboards in the resident electronic medical record. Providers typically clicked a button indicating the labs were reviewed however nursing could do that as well. They were not sure why the resident's labs were not reviewed, and when it was reviewed, it was not done timely. During a telephone interview on 6/10/2024 at 10:05 AM, Nurse Practitioner #16 stated if they ordered acute labs for a resident, they typically followed up the next day to review the results. If routine scheduled labs were completed, they expected nursing to notify them as soon as possible of any alterations. They wanted to be notified of lab results such as a high white blood cell count and elevated blood urea nitrogen. They believed they did not work on 2/16/2024 and did not review the resident's labs until after the resident was discharged to the hospital. If they had known the resident's white blood cell count was high, they would have intervened and ordered a chest x-ray and/or urinalysis (often used to check for urinary tract infections). For the elevated blood urea nitrogen, they would have ordered extra hydration (fluids) by mouth or intravenously (through a vein). Earlier intervention could have resulted in a different outcome for the resident. During a telephone interview on 6/11/2024 at 8:55 AM, Registered Dietitian #14 stated if there was a concern with lab values, the provider notified them. Laboratory values they would want to be notified about included a high blood urea nitrogen or high sodium because those could indicate dehydration. If they were made aware of the lab results, they would have done an assessment and discussed interventions with the provider. They were not aware the resident had altered lab values on 2/15/2024. 2) Resident #153 had diagnoses including Type 2 diabetes (the pancreas does not make enough insulin needed for control of blood sugar), traumatic brain injury, and dementia. The 5/17/2024 Minimum Data Set assessment (health assessment screening tool) documented the resident had moderate cognitive impairment, was usually understood, and received a hypoglycemic medication (used to reduce the amount of sugar in the blood). The 8/15/2022 Comprehensive Care Plan documented the resident had non-insulin dependent diabetes. Interventions included monitor for signs and symptoms of hyperglycemia (high blood sugar), administer medications per physician order, monitor blood glucose finger stick, monitor for signs and symptoms of hypoglycemia including confusion, lethargy, decreased blood sugar, diaphoresis (sweating) and tachycardia (high heart rate), and monitor labs and notify physician of abnormal values. Physician orders documented: - on 3/2/2023 provide a controlled carbohydrate diet - on 3/2/2023 finger stick (measure blood sugar) daily before breakfast and dinner. Call medical provider if less than 70 milligrams/deciliter or greater than 250 milligrams/deciliter. - on 3/2/2023 glucagon emergency kit (used to treat very low blood sugar), inject 1 milligram intramuscularly as needed for severe hypoglycemia (low blood sugar) once as needed. - on 10/19/2023 glipizide extended release (stimulates release of insulin) 5 milligrams once daily. On 5/16/2024, Physician #41 documented the resident was seen for a routine visit. The resident had type 2 diabetes and had improved with the current medication regime. The 6/14/2024 physician order documented comprehensive metabolic panel (blood test that measures chemical balance and metabolism) related to diabetes without complications. The 6/2024 Medication Administration Record documented: - metformin (an oral medication used to treat high blood sugar levels) 1000 milligrams twice daily at 7:00 AM-10:00 AM and at 7:00 PM-9:00 PM. A 6/20/2024 Licensed Practical Nurse #87 progress note documented the resident refused their 6:00 AM finger stick. The resident refused 3 attempts. A 6/20/2024 at 11:00 AM, Assistant Director of Nursing #25 progress note documented the resident was alert and able to verbalize their needs. They refused to take their medication and they were tired of taking all their medications. The resident verbalized an understanding of their need for medications, but still refused. The resident's family was called, and they encouraged the resident to take their medications. Their family stated they would come to the facility to encourage the resident to take their medications and allow staff to obtain blood work. A 6/20/2024 at 1:00 PM progress note by Registered Nurse Unit Manager #94 documented they were able to administer the resident's medications after numerous attempts. A 6/20/2024 at 3:24 PM Assistant Director of Nursing #25 progress note documented the resident's family came to the facility and convinced the resident to allow a blood draw. The Assistant Director of Nursing drew the blood for the ordered lab work with the family present. The facility lab results report documented a lab specimen was collected on 6/20/2024 at 3:13 PM and received by the laboratory on 6/21/2024 at 3:04 PM. The lab results were flagged with a red stop sign to indicate a critical glucose result of 49 milligrams/deciliter (normal 70-99). The report documented the glucose result was called to and read back by Registered Nurse #89 on 6/21/2024 at 5:46 PM. The bottom of the report had a space to sign and date when the results were reviewed. There was no documentation the results were reviewed on the day they were received. The top of the lab result documented it was reviewed by Nurse Practitioner #22 on 6/25/2024 at 9:29 AM, 4 days after the results had been reported to the facility. There was no documented evidence a medical provider was notified of the critical glucose result of 49 milligrams/deciliter, or the resident was assessed for signs and symptoms of hypoglycemia. During a telephone interview on 6/25/2024 at 8:33 AM, the laboratory services Hematology Manager #96 stated the lab called the facility's nurse call line and asked who they were speaking to and read the results to the nurse. The nurse read back the results, and the lab services would document the date and time of the call. During an interview on 6/25/2024 at 9:09 AM Registered Nurse #89 stated they were a Nursing Supervisor and mainly covered the Letter building. Resident #153 had a blood draw completed on 6/20/2024 around 3:15 PM. On 6/21/2024 at 5:26 PM they received a call from the lab stating the Resident #153 had a glucose of 49. They felt the lab should have called the facility sooner. They were completing an admission assessment on another resident at the time of the call, but they called the unit to check on Resident #153. They were told the resident had taken all their medications. They should have called a medical provider to let them know the resident had a critical result of 49 to get further orders. During an interview on 6/25/2024 at 9:11 AM, Medical Director #11 stated if a resident had an ordered blood draw the facility's lab services contacted the facility with abnormal/ critical results. They called the Nursing Supervisors or Registered Nurse Unit Managers, who would then contact the medical staff to get further direction. If a resident had low glucose, they should be assessed by a registered nurse and the medical staff (physician or nurse practitioner). The lab results also were posted in the electronic medical record system so all nursing and medical staff could view them. If a resident had a glucose result of 49, they should have been assessed by a Registered Nurse and the medical staff should have been contacted. They did not see any documentation in the resident's electronic medical record regarding a glucose of 49. They expected medical staff to be notified and if medical was not notified it could affect the resident's medical condition. During an interview on 6/26/2024 at 1:32 PM, laboratory services Hematology Manager #96 stated the lab services protocol for the facility was to call the nursing call line and read back critical results. On 6/21/2024, the lab services called the facility and reported a critical result glucose result of 49 for Resident #153 to Registered Nurse #89. During a follow up interview on 7/2/2024 at 9:24 AM, laboratory services Hematology Manager #96 stated they looked at the collection tube for Resident #153 from 6/202/204 and there was not collection time documented, but the lab did call Registered Nurse #89 on 6/21/2024 about the critical result. 3) Resident #260 had diagnoses including non-traumatic ischemic infarction (disrupted blood flow) of the right lower leg, mitral valve (a heart valve) replacement, and atrial fibrillation (irregular heart rhythm which can lead to blood clots in the heart). The 5/31/2024 Minimum Data Set assessment documented the resident was cognitively intact and received an anticoagulant (blood thinner). The 3/10/2024 Comprehensive Care Plan documented the resident was at risk for bleeding secondary to anticoagulant use related history of deep vein thrombosis (blood clot that forms in one or more of the deep veins in the body). Interventions included to administer medications as prescribed, monitor effectiveness of medications given and observe for adverse reactions, handle resident gently during care and support the extremities under joints during movement, monitor for signs and symptoms of abnormal bleeding (skin bruising, bleeding gums, black stools, coffee ground like emesis, blood in urine), monitor lab values as ordered and notify medical of abnormal findings (PT, INR), and refer to dietary for diet modifications as needed. Physician orders documented: - on 5/28/2024 PT/INR (prothrombin time/international normalized ratio, used to measure how long it takes blood to clot) every Monday and Thursday and INR goal of 2.5-3.5. - on 6/4/2024 warfarin sodium (Coumadin, an anticoagulant) 1 milligram at bedtime for valve (regular orders for warfarin sodium were documented based on INR results). - on 6/14/2024 PT/INR one time only to monitor INR related to non-traumatic ischemic infarction of muscle of right lower leg. The facility lab results report documented a lab specimen was collected on 6/13/2024 at 8:07 AM and received by the laboratory on 6/13/2024 at 11:59 AM. The lab results were flagged with a red stop sign to indicate critical results of an INR of 5.77. The report documented the INR result was called to the facility and read back by (only first name documented with no title) on 6/13/2024 at 12:29 PM. The top of the lab result documented it was reviewed by Nurse Practitioner #22 on 6/13/2024 at 3:36 PM. A 6/13/2024 at 5:09 PM progress note by Registered Nurse #15 documented labs were reviewed by the nurse practitioner. Warfarin was held and labs would be repeated in the morning. There were no documented physician orders to hold warfarin on 6/13/2024. The facility lab results report documented a lab specimen was collected on 6/14/2024 at 9:12 AM and received on 6/14/2024 at 11:46 AM. The lab results were flagged with a red stop sign to indicate critical results and included an INR of 5.05. The report documented the INR result was called to the facility and read back by Assistant Director of Nursing #25 on 6/14/2024 at 1:03 PM. The bottom of the report had a space to sign and date when the results were reviewed. There was no documentation the results were reviewed on the day they were received. The top of the lab result documented it was reviewed by Nurse Practitioner #22 on 6/15/2024 at 10:29 AM. The 6/14/2024 at 10:06 PM Registered Nurse #15 progress note documented the INR was reviewed with the nurse practitioner. The warfarin would be held as ordered and repeat labs as ordered. There were no documented physician orders to hold warfarin on 6/14/2024. There were no documented medical provider progress notes referencing the critical INR values on 6/13/2024 and 6/14/2024. The 6/2024 Medication Administration Record documented the resident did not receive warfarin on 6/13/2024 and 6/14/2024. During an interview on 6/25/2024 at 9:11 AM, the Medical Director stated the facility was notified by the laboratory of critical lab results. The laboratory would usually report the labs to the Nursing Supervisor or the Unit Managers. The nurses would then call the provider to report the results and receive direction on how to proceed. The provider should be notified of critical lab results immediately so they could be urgently addressed. If an INR was out of range, it could be considered a critical lab value. If INRs were reported to the facility between 5:00 PM-7:00 AM the telehealth provider should be notified. Resident #260's INRs were addressed by Nurse Practitioner #22 after the registered nurse notified them, and the warfarin was held on 6/13/2024 and 6/14/2024. If an INR falls outside the range of 2.5-3.5 for a mechanical heart valve, the provider needed to be notified to determine if further action was needed. During an interview with Nurse Practitioner #22 on 6/25/2024 at 9:13 AM, they stated if there were any critical laboratory values the facility's contracted laboratory called the nursing supervisor and informed them of the critical values. The nursing supervisor would then call them during the day if critical values were called in during the off shifts and the on-call medical provider would be notified. They checked the Dashboard (feature in the electronic medical record that alerted staff to outstanding/ critical laboratory values) twice daily each unit. If they noticed any outstanding/ critical laboratory values, they reviewed the resident's record and saw the resident. Resident #260 had an artificial heart valve. If an INR falls outside the range of 2.5-3.5 for a mechanical heart valve, the provider needed to be notified to determine if further action was needed. Resident #260's INR was 5.35 and they ordered their scheduled warfarin to be held 6/24/2024 at 3:22 PM and ordered another INR to be completed on 6/25/2024. The resident received their warfarin in the evening, so they documented their note later in the day. If they held the resident's warfarin too much, they would get subtherapeutic (a dose that is below what is used for treating disease or producing an optimal therapeutic effect) levels. They would consider prescribing vitamin K if the resident's INR was 5 -6 and if the resident was bleeding. They thought the nursing supervisor documented when the laboratory called the facility with critical values, but they did not see any documentation at this time. 10 NYCRR 415.20 _____________________________________________________________________________________ Immediate Jeopardy was identified, and the Administrator was notified on 6/27/2024 at 7:00 PM. Immediate Jeopardy was removed on 7/3/2024 at 11:43 AM prior to survey exit based on the following corrective actions taken. As of 7/3/2024 at 9:00 AM, 86% of all licensed nursing staff have been educated on laboratory services. The remaining staff will be educated prior to the start of their next shift. Post-tests were reviewed. Staff education sign in sheets were reviewed and compared to the current nursing staff list and no discrepancies were identified. 100% of licensed nursing staff currently working on 7/3/2024 received education. Staff education was verified during an onsite visit(s) 7/3/2024, multiple licensed nursing staff on multiple units were interviewed to determine retention of education provided and were able to accurately report content of the education. 35045 44838 48895

Based on observation, record review, and interviews during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility failed to ensure that pain management was provided to residents who required such services consistent with professional standards of practice for 3 of 7 residents (Resident #28, #37, and #64) reviewed. Specifically, -Resident #28's physician ordered pain cream was not administered as ordered and was documented as administered. -Resident #37 did not receive Lyrica (used to treat nerve and muscle pain) as ordered for 3 days; -Resident #64 was not aware of an as needed order for acetaminophen (pain reliever) and pain cream and was not offered the medications when in pain. Subsequently, Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life. This placed all residents with pain, who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care. Findings include: The facility policy, Pain Management, revised 3/2020, documented the facility was committed to reducing physical and psychosocial symptoms associated with pain to assist the resident in achieving their highest practicable level of functioning. The facility policy, Medication Administration, revised 1/2021, documented medications were administered in a safe and timely manner, and as prescribed. The individual administering the medication must initial the medication administration record after giving each medication and before administering the next. Topical medications must be recorded on the treatment administration record. If a drug was withheld or refused, the individual administering the medication initialed and circled the medication treatment record space for that drug. The 4/2020 facility policy Pharmacy Services, documented pharmacy services were available to resident 24 hours a day, seven days a week. The pharmacy was to provide and maintain the facility's emergency medication supply. Residents had sufficient supply of their prescribed medications and received medications (routine, emergency or as needed) in a timely manner. Nursing staff communicated prescriber orders to the pharmacy and were responsible for contacting the pharmacy if a resident's medication was not available for administration. Borrowing medication from another resident or from emergency medication supply because of a failure to reorder medications in time for a resident to receive a scheduled medication was not acceptable practice. The pharmacy policy for the Automated Dispensing System, dated 2/2023, documented the purpose of the system was to allow a nurse to add a patient to the system and withdraw medication in emergency situations. The unit would provide an emergency controlled substance dose of the desired medication from the respective emergency-kit. The automatic dispensing system would allow a nurse the capability of obtaining only one dose of a medication from an emergency-kit pursuant to a prescriber's order. All medication removed from the unit must be signed out to a patient and must have a physician order. 1) Resident #28 had diagnoses including cervical disc disorder (breakdown of the spinal discs in the neck), radiculopathy (pinching of the nerves at the root), and displaced fracture (bone is out of alignment) of the right femur (thigh bone). The 4/21/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial assistance for most activities of daily living, received scheduled and as needed pain medications, and did not have pain. The resident felt down, depressed, or hopeless half or more of the days, had trouble falling asleep or staying asleep nearly every day, and did not reject care. The Comprehensive Care Plan, initiated 8/31/2022, documented Resident # 28 had an alteration in comfort related to cervical disc disorder, radiculopathy of the lumbar spine, and displaced fracture of the right femur. Interventions included administering pain medication as ordered. A 6/23/2023 orthopedic consult documented the resident had retrograde pain in the right femur (thigh bone) and right knee. The resident had right knee pain all day and diclofenac gel (a topical pain cream) decreased the pain. The resident had osteoarthritis in the right knee. Physician orders documented: - on 9/8/2023 diclofenac gel 1% apply to bilateral (both) knees four times a day and acetaminophen (used to treat pain) 325 mg 2 tablets every six hours as needed for pain. Pain evaluation every shift record pain on a 0-10 scale. - on 4/19/2024 gabapentin (nerve pain medication) 300 milligrams three times a day for pain. - on 6/1/2024 oxycodone HCL (narcotic pain reliever) 5 milligrams every 8 hours as needed for pain. The 5/2024 Treatment Administration Record documented a pain evaluation every shift, record on a pain scale of 0-10. The resident's pain level was not documented 11 of 93 shifts and was documented as a 0 for 82 of 93 shifts. The 5/2024 Medication Administration Record documented diclofenac gel 1%, apply to bilateral knees topically four times a day for pain at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. The diclofenac was documented as administered 5/1/2024-5/31/2024 as ordered except for the 9:00 PM administrations on 5/2/2024 and 5/9/2024. The 6/2024 Medication Administration Record documented diclofenac gel 1%, apply to bilateral knees topically four times a day for pain at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. The diclofenac was documented as administered from 6/1/2024-6/9/2024, for the 9:00 AM dose on 6/10/2024, from 6/11/2024-6/17/2024, for the 9:00 AM and the 9:00 PM doses on 6/18/2024, and from 6/19/2024-6/23/2024 as ordered. The medication was marked as other see nurses note on 6/10/2024 for the 1:00 PM, 5:00 PM, and 9:00 PM doses. On 6/18/2024, the 1:00 PM dose was marked as out of facility and the 5:00 PM dose was marked as refused. The resident was discharged to the hospital prior to their first scheduled dose on 6/24/2024 and remained in the hospital for the remainder of 6/2024. During an observation and interview on 6/4/2024 at 11:57 AM, Resident #28 stated they never got their diclofenac gel as ordered and they wanted it as it helped their knee pain. During an observation and interview on 6/6/2024 at 1:18 PM, Resident #28 stated they got their diclofenac gel yesterday (6/5/2024) but did not receive it today. During an observation and interview on 6/7/2024 at 8:39 AM, Resident #28 stated they did not get their diclofenac gel yet and would like it as it helped with the pain. Resident #28 stated they were evaluated yesterday by an orthopedic doctor for shoulder pain and wanted the diclofenac gel applied to their shoulder also as they believed it would help their pain. During an observation and interview on 6/10/2024 at 9:42 AM, Resident #28 was in bed with facial grimacing. They stated they received all their medications except the diclofenac gel. They reported they were in pain and would like the medication as it helped with pain. They stated they were able to get out of bed easier when it was administered. A 6/11/2024 Nurse Practitioner #16 progress note documented a pain assessment was completed. The resident had right shoulder pain of a 6. Position changes and medication eased the pain. The resident stated the diclofenac cream to the knees was helping. The plan was to order diclofenac for bilateral shoulders four times a day for pain and discomfort. The June 2024 medication administration record documented diclofenac sodium 1 %, apply to bilateral shoulders topically four times a day for pain 2 grams with a start date of 6/11/2024 at 1:00 PM. The medication was scheduled to be applied at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. The diclofenac was documented as administered as ordered from 6/11/2024-6/17/2024, the 9:00 AM and the 9:00 PM doses on 6/18/2024, and from 6/19/2024-6/23/2024. On 6/18/2024, the 1:00 PM dose was marked as out of facility and the 5:00 PM dose was marked as refused. The resident was discharged to the hospital prior to their first scheduled dose on 6/24/2024 and remained in the hospital for the remainder of 6/2024. During an interview on 6/6/2024 at 10:30 AM, Certified Nurse Aide #20 stated Resident #28 told them on multiple occasions they did not get their diclofenac gel for pain, and they had told the nurse and the Unit Manager. They stated Resident #28 was cognizant and could experience more pain if they did not receive the diclofenac gel. During an interview on 6/6/2024 at 10:51 AM Licensed Practical Nurse #33 stated diclofenac gel was for pain and Resident #28 had an order for it to be administered to their knees. They stated many residents complained about not getting creams, inhalers, eye drops or other non-oral medications. Without the pain gel Resident #28 could experience more pain and be less mobile. During an interview on 6/10/2024 at 11:50 AM, Licensed Practical Nurse #34 stated diclofenac gel was used for pain, Resident #28 had an order for diclofenac gel, and they did not get it today. They stated they signed for the 9:00 AM diclofenac even though it was not administered. They only administered oral medications initially and went back to administer creams, gels, nasal sprays, inhalers, and other treatments. When they would go back to administer the gel if the resident was not in their room or if they refused, they struck out the medication on the Medication Administration Record. They signed for the 9:00 AM administration because they always signed for all morning medications when they administered the morning oral medications and would come back later to administer creams, nasal sprays, and other treatments because that is how they were trained. On 6/25/2024 at 10:16 AM, Licensed Practical Nurse #34 stated they were trained to pass oral medications first. If they are not able to do the gels, like the pain relief gel, due to a resident not being available, they came back and did it later. There was no documented evidence Licensed Practical Nurse #34 completed a competency for medication administration. During an interview on 6/10/2024 at 3:36 PM, Licensed Practical Nurse Unit Manager #13 stated Resident #28 told them on several occasions that staff did not apply their diclofenac gel for pain as ordered and they told the resident to ask the medication nurse for it. They stated residents should not have to ask for medications that were ordered routinely. They stated medications should only be signed as administered after being administered. If nursing staff documented something that was not done, they would have to go back and strike the record and write a note referencing the strikeout. During an interview on 6/11/2024 at 11:54 AM Assistant Director of Nursing #24 stated they expected residents to receive medication as ordered including diclofenac gel and they should not have to ask for the medication unless it was ordered as needed. During a phone interview on 6/25/2024 at 8:16 AM, the resident stated most days the nurses did not apply the pain relief gel. They stated they needed the pain relief gel, especially on their knees, as they could not get up in the morning because of the pain. They could not wheel their wheelchair due to pain in their arms. They stated the pain in their knees was mostly an 8 to 9 on a 1-10 pain scale when getting up with the transfer equipment or getting dressed. The pain improved with the diclofenac. They were not aware of any other pain medication available to them. They stated when they were in pain, they were miserable and felt depressed. They stated it affected them wanting to go to activities. They told staff nearly every day, including Licensed Practical Nurse Unit Manager #13, they did not get their diclofenac gel and wanted it to improve their pain. During an interview on 6/25/2024 at 10:16 AM, Licensed Practical Nurse #34 stated they were trained to pass oral medications first. If they were not able to do the gels, like the pain relief gel, due to a resident not being available, they came back and applied it later. During an observation and interview on 7/8/2024 at 11:29 AM, the resident was sitting in their wheelchair in their room and stated they had not received their pain relief gel to their shoulder or knees yet that day but had received their oral medication. Their pain in their shoulder was an 8 out of 10 and their knees were a 5 out of 10. They stated they would like their pain relief gel. During an interview on 7/8/2024 at 11:43 AM, Licensed Practical Nurse #89 stated they would ask a resident if they were in pain and offer pain medication. If they had nothing ordered, they called the supervisor to call the provider. They were done with the morning medication pass and had not applied the pain relief gel for Resident #28 as they had not gotten to their treatments yet. The pain relief gel was on the resident's treatment administration record not their medication administration record. They did not believe they had signed for it but if they had it would not be a good idea as the resident could refuse or not be in their room. Medications could be administered one hour before and one hour after the scheduled time. They reviewed the medication administration record and stated the diclofenac was ordered as a medication and it was not signed for. The next schedule administration time would be 1:00 PM as they missed the 9:00 AM dose and could not administer it the 9:00 AM dose now. If residents did not get pain medications, they could have more pain, and which may impact their daily living. The resident may get depressed and sad. During an interview on 7/10/2024 at 9:31 AM, Assistant Director of Nursing #25 stated they expected orders for pain medications to be administered and administered timely. If a medication was ordered for 9:00 AM, the nurse had one hour before and one hour after the scheduled time to administer the medication. If a resident did not get pain medication as ordered, they could be in pain which could compromise behaviors. If a nurse missed the medication time, they should call the supervisor and the provider to get direction. A missed medication was a medication error. They expected the nurse to call the Unit Manager or Supervisor and write a note to why it was not given. 2) Resident #37 had diagnoses including diabetic neuropathy (nerve damage) and chronic venous insufficiency (damaged veins that can cause inflammation). The 5/29/2024 Minimum Data Set assessment (a health assessment screening tool) documented the resident was cognitively intact, did not reject care, frequently felt down, depressed, or helpless, had frequent trouble falling or staying asleep, felt bad about themself, had trouble concentrating, and had thoughts they would be better off dead, or of hurting themself in some way. The resident received a scheduled pain medication regime, received as needed pain medication, had almost constant pain that made it hard for them to sleep at night, and the pain constantly limited their day-to-day activities, and the resident's worst pain was a 10 (0-10 pain scale with 10 being the highest pain level). The Comprehensive Care Plan initiated 9/29/2022 documented the resident had an alteration in comfort related to neuropathy, back pain, and intermittent claudication (muscle pain from poor blood flow). Interventions included administer medications as ordered, report to the nurse resident complaints of pain or requests for pain treatment, notify physician if interventions were unsuccessful of if current complaint was a significant change from the resident's experience with pain, monitor for signs and symptoms of pain, if resident appeared to be in pain utilize appropriate non-pharmacological interventions. Interventions were revised on 5/30/2024 and included evaluate effectiveness of pain intervention, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, and observe for new onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness, and falls, and report occurrences to the physician. Physician orders documented: - on 9/27/2022 physiatry-physical medicine and rehab consult for evaluation and treatment of pain. - on 4/23/2023 monthly medications would be dispensed for 30 days unless otherwise indicated and refillable 5 times upon monthly re-evaluation and renewal of orders by prescriber. - on 5/22/2024 pain evaluation every shift, record pain on a 0-10 scale. - on 5/22/2024 Lyrica oral capsule 100 milligrams, give 1 capsule every 12 hours for neuropathy, maximum daily dose 2 capsules. A 5/29/2024 Pain Interview completed by Licensed Practical Nurse #85 documented the resident experienced pain almost constantly. The pain almost constantly affected the resident's sleep and interfered with day-to day activities. The resident rated their pain intensity at a 10. The resident was on a scheduled pain medication regimen and received as needed pain medications without much help. The 6/2024 Medication Administration Record documented Lyrica oral capsule 100 milligrams, give 1 capsule by mouth every 12 hours for neuropathy at 9:00 AM and 8:00 PM. - on 6/21/2024 Lyrica was last administered at 9:00 PM by Licensed Practical Nurse #86. - on 6/22/2024 Lyrica was documented as a 9 (other/see nurse notes) at 9:00 AM by Licensed Practical Nurse #53, and at 8:00 PM by Licensed Practical Nurse #28 - on 6/23/2024 Lyrica was documented as a 9 at 9:00 AM by Licensed Practical Nurse #87, and at 8:00 PM by Licensed Practical Nurse #28. - on 6/24/2024 Lyrica was documented as a 9 at 9:00 AM by Licensed Practical Nurse #28 and documented as administered at 8:00 PM by Licensed Practical Nurse #28. Nursing notes documented: - on 6/22/2024 at 10:37 AM by Licensed Practical Nurse #53 Supervisor was aware that Lyrica needed to be ordered, not available in Pyxis (an automated medication dispensing system). - on 6/22/2024 at 8:58 PM by Licensed Practical Nurse #28 the Lyrica was on order, was awaiting pharmacy to deliver. - on 6/23/2024 at 8:18 AM by Licensed Practical Nurse #87 the Lyrica was not on hand. - on 6/23/2024 at 8:44 PM by Licensed Practical Nurse #28 the Lyrica was on order, waiting for the pharmacy to deliver. - on 6/24/2024 at 9:14 AM by Licensed Practical Nurse #28 the Lyrica was on order, waiting for the pharmacy to deliver. The nursing notes did not document the resident's pain level. The 6/2024 Treatment Administration Record documented pain evaluation every shift. The residents pain level was documented: - on 6/22/2024 at an 8 for the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts; and a 0 for the 11:00PM-7:00 AM shift. - on 6/23/2024 at a 0 for the 7:00 AM-3:00 Pm shift; an 8 for the 3:00 PM-11:00 PM shift; and a 0 for the 11:00 PM-7:00 AM shift. - on 6/24/2024 at a 7 for the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. The 6/24/2024 at 3:49 PM progress note transcribed by Nurse Practitioner #22 and signed by the Medical Director documented the resident's pain was a 7 on 6/24/2024 at 10:46 PM. The resident had chronic lower extremity pain. The resident did not feel their pain was fully compensated on oxycodone (an opioid pain reliever) every 12 hours and the oxycodone was increased to every 8 hours. The resident stated their neuropathic pain in the lower extremities was worse. The resident did not think they received their Lyrica that morning. They spoke with the Nurse Manager who would check on the administration of the resident's Lyrica. On 6/24/2024 at 9:19 PM Registered Nurse Supervisor #89's progress note documented the resident was short of breath with an oxygen concentration of 80% on 2 liters of oxygen and denied pain. Resident requested to go to the hospital and Emergency Medical Services was called. The 6/27/2024 Automatic Dispensing System's Usage Report documented 4 pregabalin (generic name for Lyrica) 25 milligrams were taken from the machine for Resident #37 on 6/24/2024 at 4:43 PM by Licensed Practical Nurse #2 and Licensed Practical Nurse #28. The 6/27/2024 Automatic Dispensing System's Inventory Summary documented pregabalin (Lyrica) 25 milligrams was available in the automatic dispensing system. The 7/11/2024 Order Audit Report documented that pregabalin (Lyrica) 100 milligrams was on-hand and dispensed on 6/24/2024. The previous distribution documented the status was reordered and exhausted on 6/24/2024. During an interview on 6/24/2024 at 10:19 AM, Resident #37 stated they had frequent chronic pain. The pain affected their regular activities, and ability to attend therapy. They had to go out to the hallway to ask for medications and that was embarrassing. Sometimes their pain limited their ability to get up and out of bed. Their pain also played into the depression they were diagnosed with after being admitted to the facility. Some days it was difficult to get up and they asked for their medications. If they were up in their chair they could go to the nurse at the cart and ask but on the night shift, they could not do that. If they did not get their pain medications at night, it made it hard to function in the morning. At 4:44 PM, the resident stated they had not gotten their Lyrica since 6/21/2024. They stated the Lyrica and oxycodone worked well together. Facility staff informed them they had ordered it last Monday 6/17/2024. During an interview on 6/25/2024 at 9:32 AM, Licensed Practical Nurse #28 stated Resident #37 had consistent pain. The resident ran out of scheduled Lyrica on 6/21/2024 and they ordered the medication through the pharmacy. On 6/22/2024, they notified the Supervisor (could not recall which Supervisor) the resident did not have medication available. Resident #37 did not receive their Lyrica on 6/22/24, 6/23/24, and 6/24/24 morning dose. During a telephone interview on 6/26/2024 at 9:58 AM, Resident #37 stated that they were sent to the hospital. The pain in their legs was so bad, they could not breathe. They stated they received their Lyrica at approximately 5:30 PM Monday night (6/24/2024) before they went to the hospital. During a telephone interview on 6/26/2024 at 2:03 PM, the pharmacy Director of Client Services #93 stated the electronic medical record had a resupply request that sent an electronic transmission to the pharmacy. Lyrica was a controlled substance, and the records indicated the resupply was requested on 6/24/2024. The inventory log for the emergency Pyxis (an automatic medication dispensing system) documented there was a form of Lyrica on hand in the facility. At 3:15 PM, they stated the letters building of the facility was stocked to its normal stocking of 10, 25-milligram tablets. No Lyrica was removed from this machine on 6/22/2024 or 6/23/2024. Lyrica was not removed from the Pyxis until 6/24/2024, when four tablets were removed. During an interview on 6/25/2024 at 9:32 AM, Licensed Practical Nurse #28 stated the resident was in constant pain. If a resident stated they were in pain, pain medications should be given timely. The resident's Lyrica ran out on 6/21/2024. The Licensed Practical Nurse Unit Manager #2 called the pharmacy on 6/21/2024. Licensed practical nurses notified the supervisor if medications were not given to a resident. They notified the supervisor (unable to recall what Supervisor) on 6/22/2024 the Lyrica was not there. They asked to check the Pyxis and was told there was not any Lyrica in the machine. They always put a note in when medication was not given but did not always write a note that the Supervisor was notified. They would not contact the provider directly. The facility policy was for the licensed practical nurse to call the Supervisor and the Supervisor would notify the provider. During an interview on 6/25/2024 at 9:54 AM, Licensed Practical Nurse Unit Manager #2 stated the resident constantly had pain in their lower back and legs from diabetic pain, wound pain, and vascular pain. The resident's pain can stop them from doing activities, like therapy. The resident's Lyrica was low on 6/21/2024 and the resident had a refill left on the order, so it was ordered. The medication was supposed to be on the 4:00 PM pharmacy run on 6/21/2024. They did not work the weekend and was informed on 6/24/2024 that they medication still had not come in. They called the pharmacy on 6/24/2024 and was informed it would be on the next run. The Pyxis contained Lyrica, so they pulled four 25 milligram tablets. All licensed nurses had access to the Pyxis and two nurses are required to verify removal for controlled substances. During an interview on 6/25/2024 at 10:31 AM, Nurse Practitioner #22 stated that any missed dose of medication was unacceptable. They expected to be notified about missed doses but was not. The nursing staff did not inform them about the missed doses. The resident informed them on 6/24/2024 when they were rounding on the unit and pulled them aside to inform them, they did not feel well. The resident's narcotic (the Lyrica) had refills. Lyrica was available in the emergency backup Pyxis. The nurses just had to call them or the pharmacy. During an interview on 7/3/2024 at 10:23 AM, Licensed Practical Nurse #87 stated they did not give the resident their Lyrica and they informed their supervisor (could not recall what Supervisor). They stated if a resident was out of a narcotic, they would fill out a narcotic sheet but was unsure if they did. The Pyxis had 25 milligram pills of Lyrica and the 25 milligram medications could be used to equal the resident's ordered dose of 100 milligrams. They did not go to the Pyxis. If there was no note in the medical record, they did not notify the supervisor or go to the Pyxis as they did not have time. During an interview on 7/8/2024, at 1:47 PM, Licensed Practical Nurse #28 stated they had not been provided with Pyxis training. During the 8:00 PM medication pass on both 6/22/2024 and 6/23/2024, they notified the Supervisor that the medication was unavailable. They were unsure which nursing supervisor they spoke with on 6/23/2024. During an interview on 7/8/2024 at 3:42 PM, Registered Nurse #89 stated they worked 6/22/2024. They did not have a note in the computer they were notified of the resident's Lyrica not being available. If they were notified, they would have gotten the medication from the Pyxis. They should have been notified and the resident should have received the medication as ordered. During an interview on 7/9/2024 at 10:27 AM, Registered Nurse #94 stated they worked on both 6/22/2024 and 6/23/2024. They did not recall being notified that the resident's Lyrica was not available. They stated there was no documentation from them regarding the resident being out of their Lyrica, so they were not aware. The registered nurse supervisor or Unit Manager would be responsible to notify the provider. During an interview on 7/9/2024 at 11:44 AM, Licensed Practical Nurse #53 stated they worked 6/22/2024. The resident received Lyrica, but they did not have it in the cart, and it was not in the Pyxis. They stated if they did not give the medication, it was because it was not in the Pyxis. They would have notified the supervisor, but they did not recall what supervisor was on. 3) Resident #64 had diagnoses including gout (inflammation of the joints), chronic pain syndrome, and left knee contracture (tightening of muscles or tendons). The 3/12/2024 Minimum Data Set assessment documented the resident was cognitively intact, had trouble falling asleep or staying asleep nearly every day, felt down, depressed, or hopeless half or more of the days, had little interest or pleasure in doing things several days, did not reject care, received a scheduled pain medication regimen, did not receive as needed pain medications, and the resident did not have pain. The Comprehensive Care Plan initiated 12/31/2019 documented the resident had chronic hip pain related to chronic degenerative changes. Interventions included anticipate the resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management of that pain and impact on function; identify previous response to analgesia including pain relief, side effects, and impact on function; identify, record, and treat existing conditions which may increase pain; monitor for probable cause of each pain episode; monitor/document side effects of pain medication; monitor/record/report any signs and symptoms of non-verbal pain; notify physician if interventions were unsuccessful or if current complaint was a significant change; observe and report changes in sleep patterns, usual routine, decrease in functional abilities, decreased range of motions, withdrawal or resistance to care, or refusal to attend activities related to pain. The Comprehensive Care Plan for pain had not been revised since 1/7/2020. Physician orders documented: - on 1/24/23 diclofenac external gel 1% apply to lower extremities and shoulders topically every 6 hours as needed for pain. - on 12/12/2023 acetaminophen 325 milligrams give 2 tablets by mouth every 6 hours as needed for pain. - on 12/12/2023 acetaminophen 325 milligrams, give 2 tablets by mouth as needed for wound care, administer 30 minutes prior to dressing change. - on 12/21/2023 pain evaluation every shift, record pain on a 0-10 scale. The June 2024 Medication Administration Record documented: - diclofenac external gel 1%. Apply 2 grams to shoulders topically every 6 hours as needed for pain. The diclofenac was not administered from 6/1/2024 through 6/30/2024. - acetaminophen 325 milligrams give 2 tablets by mouth every 6 hours as needed for pain. The acetaminophen was not administered from 6/1/2024 through 6/30/2024. - acetaminophen 325 milligrams, give 2 tablets by mouth as needed for wound care, administer 30 minutes prior to dressing change. The acetaminophen was not administered from 6/1/24-6/30/2024 (the resident received wound care to their left calf and left ankle on 6/5/2024, 6/12/2024 and 6/19/2024.) - pain evaluation every shift, record pain on a 0-10 scale. From 6/1/2024-6/30/2024 the resident had a pain level of 3 on the 6/1/2024 3:00 PM-11:00 PM shift documented by Licensed Practical Nurse #66, a pain level of 3 on the 6/2/2024 7:00 AM-3:00 PM shift by Licensed Practical Nurse #66, a 10 on the 6/2/2024 3:00 PM-11:00 PM shift by Licensed Practical Nurse #66, a pain level of 4 on the 3:00 PM-11:00 PM shift on 6/9/2024, 6/18/2024, 6/20/2024, and 6/22/2024 by Licensed Practical Nurse #88, a pain level of 6 on the 6/27/2024 7:00 AM-3:00 PM shift by Licensed Practical Nurse #33, a pain level of 5 on the 6/28/2024 7:00 AM-3:00 PM shift Licensed Practical Nurse #33, and a pain level of 5 on the 6/29/2024 3:00 PM-11L00 PM shift by Licensed Practical Nurse #33. The 11:00 PM-7:00 AM on 6/29/2024 and all shifts on 6/30/2024 were marked as the resident was hospitalized . All other pain ratings were documented as 0. There were no nursing progress notes for 6/1/2024, 6/2/2024, or 6/9/2024 addressing the resident's pain ratings. A 6/7/2024 Nurse Practitioner #16 progress note documented the resident was educated on disease management and signs and symptoms to be reported to the care team. The resident was educated on how health conditions were managed by medications, including medication actions, benefits, side effects, importance of adherence, and when to discuss with the provider. The plan was to assess needs for and/or effectiveness of medications and adjust medication regime as appropriate. During an interview on 6/24/2024 at 10:08 AM, the resident stated they had pain in their left knee and hip. The pain was a 6 out of 10 but could get as high as 10. The pain was higher when they were rolled to be changed. They did not ask for pain medication because it came automatically scheduled. They did not have anything extra ordered for pain. They stated if they had something else ordered for pain, they would ask for it. They received oxycodone four times[TRUNCATED]

Based on observation, record review, and interview during the extended recertification survey conducted 6/4/2024-7/11/2024, the facility did not ensure the resident's ability to safely self-administer medications was clinically appropriate for 5 of 5 residents (Residents #21, #64, #72, #207, and #239) reviewed. Specifically, Residents #21, #64, #72, and #207 had medications that were left in their room, with some being unidentified. Resident #239 was not observed by nursing staff to ensure their controlled substance, which was used to treat narcotic addiction, was taken as prescribed. There was no documented evidence these residents were assessed to determine their ability to safely self-administer medications or had physician orders for self-administration of medication. The facility's failure to ensure residents' medications were safely administered placed all 248 residents at risk for serious harm or serious adverse outcomes. This resulted in Immediate Jeopardy to resident health and safety. Findings include: The facility policy, Medication - Self Administration, dated 7/2019, documented residents could request to keep medications at their bedside for self-administration in accordance with resident rights. The resident must be both mentally and physically capable. The staff and practitioner would assess the resident's abilities to determine appropriateness. Self-administered medications must be stored in a safe and secure place not accessible to other residents. Staff should identify and give to the charge nurse any medications not authorized for self-administration found at the bedside. Staff and practitioners would periodically reevaluate the resident's ability to self-medicate. The facility policy, Medication Administration, dated 1/2021, documented that medication must be administered in accordance with the orders. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, had determined they had the decision-making capacity to do so safely. 1) Resident #239 had diagnoses including psychoactive substance abuse and depression. The 5/16/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, independent for activities of daily living, and received an antianxiety and opioid medication daily. The 2/27/2024 Comprehensive Care Plan documented the resident had a history of substance abuse. There were no goals or interventions related to the use of Suboxone (a controlled substance used to treat narcotic addiction) or the ability to self-administer medications safely. There was no documented evidence the resident had been assessed for the ability to safely self-administer medications. A physician order dated 5/13/2024 documented the resident was to receive Suboxone sublingual (under the tongue) film 4-1 milligram. Give 4 milligrams sublingually three times a day for poly-substance abuse. The order did not include directions for self-administration of the medication. During an interview on 6/4/2024 at 2:33 PM, Resident #239 stated they received 12 milligrams of Suboxone daily and would flush 8 milligrams down the toilet. They stated they flushed it because they wanted a different medication and did not need the Suboxone. They stated they ripped the film in pieces and flushed them. The 6/2024 Medication Administration Record documented Suboxone sublingual film 4-1 milligrams. Give 4 milligrams sublingually three times a day for opioid abuse. The medication was documented as administered from 6/1//2024 through 6/8/2024 at 8:00 AM, 2:00 PM, and 8:00 PM. During an observation on 6/7/2024 at 9:19 AM, Licensed Practical Nurse #67 handed Resident #239 a cup containing their oral medications while the resident was in the hallway. The nurse opened the Suboxone film and handed it to the resident. The resident placed the oral medications in the cup in their mouth and entered their room. The resident did not place the Suboxone film in their mouth. During an interview on 6/7/2024 at 9:38 AM, Licensed Practical Nurse #67 stated Resident #239 received their medications in front of the nurse and remained in the hallway for 2-3 minutes. The Suboxone went under the resident's tongue, and they observed the resident do this. If the resident stated, they flushed their medication down the toilet they probably did. They were not aware this was happening. No residents on the unit had medication self-administration orders. During an interview on 6/7/2024 at 12:18 PM, Nurse Practitioner #22 stated they expected medications to be administered as ordered and not left at a resident's bedside. They had seen medications in resident rooms many times. They were not aware Resident #239 was not taking their Suboxone. Resident #239 could possibly hoard their Suboxone if they were allowed to self-administer medications. During an interview on 6/7/2024 at 12:18 PM, Physician #36 stated Suboxone took 4-8 minutes to dissolve, and it did not make sense for Resident #239 to throw it away. During an interview on 6/10/2024 at 3:36 PM, Licensed Practical Nurse Unit Manager #13 stated when administering medications, the nurse should make sure all medications were taken by the resident before leaving the resident. The unit had wanderers who could take other resident's medications if the nurse left them at the bedside. They expected documentation of administration to be completed by the nurse after the resident swallowed the medications. Resident #239 should be monitored for 8 minutes after administration while on Suboxone. During an interview on 6/11/2024 at 11:54 AM, Assistant Director of Nursing #24 stated self-administration of medication should be care planned. If Suboxone took 4-8 minutes to dissolve, staff should stay with the resident during that time. The resident could take it out of their mouth and save the medication. A 6/11/2024 at 1:11 PM Social Worker #107's progress note documented they and the Nurse Manger met with Resident #239. The resident left AMA (against medical advice), refused to sign the AMA form and left at 1:00 PM. Adult Protective Services was called to report the AMA. 2) Resident #64 had diagnoses including chronic pain syndrome and hand contractures (tightening of the muscles or tendons). The 3/12/2024 Minimum Data Set assessment documented the resident was cognitively intact, dependent for activities of daily living, and received an antianxiety, diuretic, and opioid medication daily. The Comprehensive Care Plan did not include documentation of the resident's ability to self-administer medications. There was no documented evidence the resident was assessed for the ability to safely self-administer medications. The resident's physician orders did not include directions for self-administration for any prescribed medications. During an observation and interview on 6/4/2024 at 10:00 AM, Resident #64 had three unidentified pills at their bedside; one round white pill etched with 10/325, one round brown pill, and one yellow oval pill etched with 125. Resident #64 stated they did not take them because they did not have anything to drink. The nurse had left them because they were sleeping. The 6/2024 Medication Administration Record documented the resident was administered the following medications by Licensed Practical Nurse #33 the morning of 6/4/2024: - Senna (a laxative) - furosemide (a diuretic) 40 milligrams - oxycodone-acetaminophen (narcotic pain reliever) 10-325 milligrams - pantoprazole (acid reducer) 40 milligrams. During an interview on 6/6/2024 at 12:48 PM, Licensed Practical Nurse #33 stated they left the medications for Resident #64 at their bedside because the resident was cognitive and reliable to take them without supervision . During an observation and interview on 6/7/2024 at 10:43 AM, there was an unidentified pill and an empty medication cup on the floor under Resident #64's bed. Licensed Practical Nurse #33 stated the medication on the floor was Senna. During an interview on 6/10/2024 at 3:36 PM, Licensed Practical Nurse Unit Manager #13 stated when administering medications, the nurse should make sure all medications were swallowed before leaving the resident. The unit had wanderers that could take medications if the nurse left them at the bedside. They expected the administration documentation be completed after the resident swallowed the medications. Resident #64 had orders for oxycodone, Senna, and medication for their gastro-esophageal reflex disease. If they did not take the medications, the narcotic could be taken too close to the next dose, or someone else could take it if it was left at the bedside. The resident could also experience constipation without the Senna. Resident #64 did not have an order for self-administration of medication. 3) Resident #72 had diagnosis including glaucoma (causes loss of vision) and diabetes with retinopathy (eye disease). The 3/24/2024 Minimum Data Set assessment documented the resident was cognitively intact, required setup or supervision for most activities of daily living, and received an anticoagulant, insulin injections, opioids, and diuretic medications daily. The Comprehensive Care Plan initiated 10/24/2022 documented the resident had impaired visual function related to glaucoma. Interventions included tell the resident where items are placed in their room. The resident was diagnosed with conjunctivitis (an eye infection) on 5/17/2023. The Comprehensive Care Plan initiated 7/19/2023 documented self-administration of medication/treatment by the resident due to the resident's desire to self-medicate, adequate vision, physical ability, and independence with decision making. Interventions included to obtain physician order for self-administration and provide a locked drawer for storage of medication and educate about locking drawer and monitor for compliance. There was no documented evidence the resident was assessed for their ability to safely self-administer medications. The resident's physician orders dated 1/1/2024 through 6/11/2024 did not include directions for self-administration of medications. The physician order summary report documented on 11/3/2023 Systane complete ophthalmic solution 0.6%, (lubricating eye drops) instill 1 drop in both eyes three times a day for dry eyes. The report documented the eye drops were discontinued (no date). During an observation on 6/4/2024 at 11:56 AM, Systane eye drops with a prescription label were observed on Resident #72's bedside table. The 6/2024 Medication Administration Record did not include Systane complete ophthalmic solution 0.6% drops. During an observation on 6/5/2024 at 8:37 AM, Systane eye drops with a prescription label were observed on Resident #72's bedside table. Resident #72 stated they did not know the eye drops were there, and the medication nurse must have left them in their room. They stated they could not self-administer the eye drops. During an interview on 6/10/2024 at 10:31 AM, Licensed Practical Nurse Unit Manager #2 stated that Resident #72 did not have an order for self-administration of medications. During an interview on 6/11/2024 at 11:01 AM, Nurse Practitioner #22 stated that residents should not have medications at their bedside. There were no residents in the facility that had approval for self-administration of any medications. Resident #72 could not self-administer eye drops. They stated they were concerned about medications at the bedside because they did not know if medications were taken, spilled, or if they needed to be monitored for therapeutic levels. The nurse administering the medication should observe every administration. During an interview on 6/11/2024 at 12:14 PM, Assistant Director of Nursing #25 stated no residents should have medications at their bedside. Resident #72 did not have the ability to self-administer eye drops and should not have them at the bedside. Someone else could have taken them, or they could over or under use the drops. The nurses should complete the task and observe that the medications were taken. __________________________________ Immediate Jeopardy was identified, and the Administrator was notified on 6/21/2024 at 7:00 PM. Immediate Jeopardy was removed on 6/22/2024 at11:30 PM prior to survey exit based on the following corrective actions taken. -87% of staff had been educated on medication administration. The remaining staff will be educated prior to the start of their next shift. -Post-tests were reviewed. -Staff education sign in sheets were reviewed and compared to the current nursing staff list and no discrepancies were identified. -100% of licensed nursing staff currently working 6/24/2024 received education. -Staff education was verified during an onsite visit(s) 6/22/2024, multiple licensed nursing staff on multiple units were interviewed to determine retention of education provided and were able to accurately report content of the education. 10 NYCRR 415.3(e)(1)(vi)

Based on observation, record review, and interview during the extended recertification and abbreviated (NY00331669) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure the physician was consulted and the resident's representative was notified when there was a significant change in the resident's physical, mental, or psychosocial status for 4 of 4 residents (Residents #37, #147, #153, and #528) reviewed. Specifically: - Resident #37 did not receive their Lyrica (used to treat nerve pain) on the day shift (7:00 AM-3:00 PM from 6/22/2024-6/24/2024 due to the facility not having the medication and the provider was not notified. Subsequently, the resident had complaints of uncontrolled pain. - Resident #147 refused heparin (a blood thinner), insulin (used to treat diabetes), and labs as ordered for a period of 6 months, the medical provider was not notified and there was not an assessment by the provider to determine the outcome of the refusals. - Resident # 153 had a critically low blood glucose level reported to the facility by the contracted laboratory service on 6/22/2024 and the provider was not notified. - Resident #528 had a change in condition including lethargy, loose stools, medication refusal, and poor food/fluid intakes and was not assessed by a qualified professional when the change was noted, the medical provider was not notified, and the resident's representative was not notified. Subsequently, the resident was hospitalized with severe dehydration. This resulted in harm to Residents #528 and #37 that was not immediate jeopardy. Findings include: The facility policy, Change in Condition Notification, revised 8/2022, documented residents would be monitored for changes in their condition, the facility staff would respond appropriately to those changes, and notify the physician and responsible party/family member of changes. The licensed nurse was to notify the resident's next of kin/responsible party when there was a significant change in the resident's condition, physical, clinical, or psychosocial well-being. In the event of a non-life threatening but significant change in the resident's condition, the facility would notify the physician. The licensed nurse would record in the resident's medical record any significant changes in the resident's condition or medical status. The facility policy, Medication Administration, last revised 1/2021 documented medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. 1) Resident #528 had diagnoses including Alzheimer's disease (a type of dementia), post-traumatic stress disorder, and anxiety disorder. The 12/29/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, was independent with bed mobility, transfers, and walking, required set-up assistance for eating, substantial assistance for dressing, and was dependent for hygiene. The comprehensive care plan initiated 12/26/2023 documented: - the resident required assistance with self-care and mobility related to Alzheimer's Disease. Interventions included supervision and set up assistance for eating and drinking, supervision with walking, and was independent with transfers and bed mobility. - The resident had behavioral symptoms such as wandering/pacing, aggression, and refusal of care. Interventions included check for hunger/thirst, toileting needs, and reapproach. - The resident used psychoactive medications related to anxiety and depression. Interventions included monitor, record, and report to the physician side effects and adverse reactions including unsteady gait, falls, refusal to eat, dry mouth, depression, diarrhea, fatigue, loss of appetite, weight loss, and behavior not usual for the person. The 1/2024 Documentation Survey Report (care log) documented the following fluid intakes (recorded in ranges): - on 1/1/2024, 480 cubic centimeters (same as milliliters) to 600 cubic centimeters; - on 1/2/202, 1320 cubic centimeters (higher intakes noted with one amount versus a range); - on 1/3/2024, 1 cubic centimeter to 160 cubic centimeters; - on 1/4/2024, 303 cubic centimeters to 663 cubic centimeters; - on 1/5/2024, 968 cubic centimeters to 1199 cubic centimeters; - on 1/6/2024, 450 cubic centimeters to 1047 cubic centimeters; - on 1/7/2024, 2 cubic centimeters to 330 cubic centimeters; - on 1/8/2024, 1710 cubic centimeters to 2060 cubic centimeters; - on 1/9/2024, 881 cubic centimeters to 1080 cubic centimeters; and - on 1/10/2024, refused or not recorded due to hospitalization . The 1/2024 Documentation Survey Report documented the following food intakes (recorded in percentage ranges): - on 1/1/2024, breakfast, lunch, dinner, and evening snack refused; - on 1/2/2024, breakfast and lunch not documented, dinner 76-100%, and an evening snack; - on 1/3/2024, breakfast, lunch, dinner refused, and no evening snack (marked not applicable); - on 1/4/2024, breakfast and lunch 0-25%, dinner 51-75%, and an evening snack; - on 1/5/2024, breakfast 0-25%, lunch 26-50%, dinner 51-75%, and an evening snack; - on 1/6/2024, breakfast and lunch 0-25%, dinner 76-100%, and an evening snack; - on 1/7/2024, breakfast 0-25%, lunch 51-75%, dinner, and evening snack refused; - on 1/8/2024, breakfast and lunch 51-75%, dinner 76-100%, and an evening snack; - on 1/9/2024, breakfast not applicable, lunch 26-50%, dinner refused, and an evening snack; - on 1/10/2024, breakfast and lunch refused, dinner resident not available (hospital). The 1/2024 Medication Administration Record documented: - on 1/1/2024, 1/5/2024, and 1/7/2024, Senna (constipation medication) was held; - on 1/5/2024, all the 7:00 PM- 9:00 PM medications were spit out; - on 1/8/2024, all the 7:00 PM to 9:00 PM medications were refused; and - on 1/9/2024, melatonin (hormonal sleep aid) was held. The electronic medication administration notes (documented separately from daily nursing progress notes) documented: - on 1/5/2024 at 8:51 PM, entered by Licensed Practical Nurse #4, the Senna (constipation medication) was held due to loose stools, the registered nurse was aware. Vital signs were stable, the resident was very tired, and fluids were encouraged. - on 1/7/2024 at 9:25 AM, entered by Licensed Practical Nurse #4, Senna was held due to loose stools, vital signs were stable, the resident was very tired, and the registered nurse was aware. - on 1/8/2024 at 7:55 PM, entered by Licensed Practical Nurse #8, the resident refused their medications and was very lethargic. - on 1/9/2024 at 1:05 PM, entered by Licensed Practical Nurse #9, the resident's appetite remained poor, and they were very tired this shift. Staff assisted the resident back to bed; they appeared unsteady on their feet and was not ambulating on the unit this shift. - on 1/9/2024 at 5:36 PM, entered by Licensed Practical Nurse #4, the resident was very tired, appeared depressed, the day shift reported reduced intakes at breakfast and lunch. Their vital signs were stable, they accepted 240 milliliters of chocolate nutritional drink on the 3:00 PM-11:00 PM shift, the Registered Nurse Unit Manager was informed at 3:00 PM. - on 1/9/2024 at 8:19 PM, entered by Licensed Practical Nurse #4, melatonin was held due to the resident being very lethargic on both day and evening shifts. The registered nurse was aware. There was no documented evidence of registered nurse assessments, medical provider notification, or evaluation related to the resident's symptoms of lethargy, loose stools, medication refusal, and loss of appetite/poor intakes from 1/5/2024 to 1/9/2024. There was no documented evidence the resident's representative was notified of the resident's change in status from 1/5/2024 to 1/9/2024. A 1/10/2024 at 1:46 PM Registered Nurse Manager #5 progress note documented the resident was unresponsive to verbal commands, their blood pressure was 121/89, pulse 99, respirations 22, oxygen was placed on the resident at 8 liters per minute, Code Blue (emergency) was called, and a crash cart (emergency supply cart) was placed at the bedside for precautions. The nurse practitioner provided orders to send the resident to the hospital for evaluation. The 1/10/2024 hospital record documented the resident was admitted for severe dehydration. Per emergency medical services, facility staff reported the resident was last seen well at 10:30 AM, and found just after 1:30 PM, minimally responsive with irregular breathing. Emergency medical services reported the resident's Glasgow Coma Scale (scale that describes the extent of impaired consciousness in all types of acute medical and trauma patients) was 5 (scale of 3-15, with 8 or less meaning severe brain injury). During an interview on 6/11/2024 at 9:45 AM, Licensed Practical Nurse #4 stated they noted a change in Resident #528's condition in the days prior to their hospitalization . The resident was normally up and walking about the unit, visiting with the nurse at the medication cart, and wanting to help staff and other residents. It was a change for the resident to be in bed, lethargic, and not eating or drinking much. The resident had reduced voiding as well. The licensed practical nurse notified the registered nurse supervisor each time they documented it on 1/5/2024, 1/7/2024, and 1/9/2024. They could not recall which registered nurse responded and was unaware if they registered nurse assessed the resident at those times. The licensed practical nurse also notified Registered Nurse Manager #5 on 1/9/2024. The licensed practical nurse stated they did not notify the medical provider due to following the chain of command and notifying the registered nurse. During an interview on 6/11/2024 at 11:48 AM, Registered Nurse Manager #5 stated a change in condition included falls, symptoms of illness, behaviors, loose stools, change in baseline functioning, fatigue, or responsiveness. When a change in condition was noted, an assessment should be completed. The licensed practical nurse should call the medical provider or a registered nurse supervisor for assessment. If the licensed practical nurse notified a registered nurse supervisor, the licensed practical nurse could still notify the physician. The registered nurse assessment and/or medical provider contact should be documented in the progress notes. The Registered Nurse Manager stated an assessment should have been completed or the medical provider notified when Resident #528 refused their medications, exhibited fatigue, loss of appetite, and loose stools. The family should have been notified once there was an assessment or a plan from the physician. They were unaware of any registered nurse or medical provider evaluations from 1/5/2024 to 1/9/2024 and was not able to access their 24-hour reports. They could not recall what happened with Resident #528 and they were not made aware of any change in their condition prior to 1/10/2024. They stated following a weekend or off-shift, they would review 24-hour shift report notes and anything the registered nurse supervisors documented. The Registered Nurse Manager could not recall being notified on 1/9/2024 by Licensed Practical Nurse #4 related to the resident's fatigue and loss of appetite. During an interview on 6/11/2024 at 2:08 PM the Director of Nursing stated a change in condition included falls, an event, or a decline in condition. A resident with reported poor intakes and lethargy should be assessed by a registered nurse and the medical provider should be notified. A licensed practical nurse could notify a medical provider, however they typically would have a registered nurse assessment prior to notification to provide the relevant information. If the licensed practical nurse notified a registered nurse for a resident's change in condition, they expected the registered nurse to notify the medical provider, not the licensed practical nurse. The family/resident representative should also be notified when the resident had a change in condition once the provider evaluated them and had a plan. When Resident #528 was noted with loose stools and a medication refusal, they would not expect a medical provider notification at that time. When the resident continued with symptoms of loss of appetite, lethargy, and poor intake, the medical provider should have been notified. Additionally, Resident #528's care plan documented to notify the medical provider of symptoms the resident had been experiencing and should have been notified immediately in accordance with their plan of care. During an interview on 6/20/2024 at 1:02 PM, Certified Nurse Aide #40 (who documented care provided on 1/1/2024, 1/3/2024, 1/6/2024, and 1/7/2024) stated they vaguely recalled Resident #528 and did not know of any concerns related to their change of condition prior to their discharge. During an interview on 6/20/2024 at 2:30 PM, Certified Nurse Aide #91 (who documented meal and care refusals on 1/7/2024 in the evening) stated the resident did not eat well due to frequent walking about the unit. The resident refused meals and needed much encouragement with offers of snacks and sandwiches. The resident could eat as they walked around. They did not recall the resident's change in condition prior to their discharge. During an interview on 6/21/2024 at 7:45 AM Physician #41 stated when the resident continued to exhibit changes such as loss of appetite and lethargy in the days prior to 1/10/2024, they should have been notified. The primary reason would be to evaluate the resident, possibly order laboratory tests, and to discuss treatment options with the family. The resident's behaviors contributed to the resident's overall condition, and further testing and monitoring were required to better understand their needs. The resident's sodium level was high indicating possible dehydration. The physician did not feel the facility contributed to the resident's decline; however, they should have notified the physician before the situation became emergent. During an interview on 6/21/2024 at 1:30 PM Certified Nurse Aide #90 stated they were assigned to Resident #528 on 1/10/2024. The resident remained in bed that morning and was alert when care was provided. The aide stated they heard from another (unidentified) aide that the resident had some changes noted such as not walking around as much per their normal behavior. The nurse (unidentified) advised Certified Nurse Aide #90 to let the resident remain in bed. The resident had been up and walking around during the previous day or two. Before lunch, they went to provide care to the resident and noted the resident was alert and said a few words. When the aide turned the resident, they thought there was a change in their breathing and immediately notified the nurse. The nurse (not identified) brought in oxygen and the machine for vital signs. The resident was sent out to the hospital. 2) Resident #147 had diagnoses including end stage renal disease (kidney disease), Type 1 diabetes (the body does not produce insulin) with polyneuropathy (nerve damage), and adjustment disorder with depressed mood. The 3/30/2024 Minimum Data Set quarterly assessment documented the resident had intact cognition, understood verbal content, did not exhibit behavioral symptoms, did not reject care, required set up assistance or supervision for activities of daily living, received an insulin injection 1 of the last 7 days, and received an anticoagulant (blood thinner) during the last 7 days. A 1/2/2024 physician order documented heparin sodium injection solution 5000 units per milliliter inject 1 milliliter subcutaneously 3 times daily for blood clot prevention (discontinued 6/26/2024) and insulin lispro (fast acting insulin) injected as per sliding scale (the amount of insulin injected is based on blood sugar reading) subcutaneously before meals for diabetes mellitus. The 1/2024- 6/2024 Medication Administration Record documented the resident received heparin on 6/3/2024 at 8:00 PM and on 6/23/2024 at 2:00 PM and 8:00 PM, all other doses during that time were not given due to refusal or resident out of the facility. The resident received blood glucose monitoring and sliding scale insulin zero times in January 2024, twice in February 2024, 5 times in March 2024, twice in April 2024, zero times in May 2024, and 9 times in June beginning 6/22/2024. The comprehensive care plan documented: - on 4/21/2022 the resident had a history of exhibiting behavior symptoms such as verbal aggression, combativeness, and refusing dialysis and care. Interventions included notify physician of new or escalating behavior. The care plan was updated on 6/21/2024 to include reapproach the resident for care/toileting/medication administration/treatments and other needs when resident is more agreeable. The resident refused medications. - on 8/15/2022 the resident had insulin dependent diabetes mellitus with interventions including administer medications per physician orders, and monitor blood glucose finger stick per physician orders. - on 10/3/2022 the resident was at risk for bleeding secondary to non-steroidal anti-inflammatory drugs/anticoagulant use prophylaxis. Interventions were to administer medications as prescribed, and monitor effectiveness of medications given and observe for adverse reactions. Drug regimen reviews completed by Registered Pharmacists #92 and #93 on 1/3/2024, 1/31/2024, 2/28/2024, 3/31/2024, 4/30/2024, 5/31/2024, and 6/30/2024 documented no recommendations. There was no mention of missed or refused medications in the reviews. Progress notes by Physician #10 dated 2/4/2024, 3/13/2024, 4/1/2024, 4/27/2024, and 5/12/2024 did not document any refusal of medications, glucose monitoring, or labs. There was no documentation of risk/benefits or alternate treatment possibilities. During an interview on 6/26/2024 at 11:33 AM Registered Nurse Unit Manager #94 stated resident refusal of medications should be communicated to the registered nurse. When refused, the medication nurse should reapproach the resident. If the resident still refused it should be documented and the registered nurse should be notified and then notify the provider. Verbal notification had been given to the physician regarding the resident's refusals. There was no evidence of documented communication with the provider. Registered Nurse Unit Manager #94 stated it was important that significant medication refusals be addressed by medical, and heparin and insulin were clinically significant medications. During an interview on 6/26/2024 at 11:46 AM Licensed Practical Nurse # 49 stated they offered resident their medications as ordered, they notified the Registered Nurse Unit Manager of refusals. They thought the Unit Manager would then notify the physician. It was important for the physician to know of refused medications. During an interview on 6/26/2024 at 1:41 PM Physician #10 stated Resident #147 was on heparin for deep vein thrombosis (blood clot) prophylaxis, and insulin sliding scale coverage for diabetes mellitus. They were notified at the beginning of June 2024 about the resident's medication refusals and had a conversation with the resident about taking medications. They did not change the orders so the medications would continue to be offered. The resident refused all labs, finger sticks, and refused heparin 90% of the time. If the resident did not receive the heparin it could lead to blood clots, and not receiving the insulin could lead to elevated blood glucose levels. During an interview on 6/27/2024 at 10:38 AM Registered Pharmacist #92 stated during the medication regimen review they looked at all medications and did look at the Medication Administration Record. If a resident refused medications and it was brought to their attention, or if they knew of refusals, they would notify the prescriber and provide options. The most important thing was notification of the provider. They ensured heparin had appropriate diagnosis, dosing per standards of practice, and lab monitoring. Refusal of medications was not included on their recommendations as the nurses should notify the medical providers. The medical provider should be made aware of refusals, and it was the medical provider's responsibility to come up with a plan. A resident who did not receive prescribed heparin could be at increased risk for a blood clots, deep vein thrombosis, pulmonary embolism (blood clot in the lung), or stroke. The physician should have been made aware of the refusal of insulin and blood glucose monitoring due to increased risk of hyperglycemia (elevated blood sugar) or hypoglycemia (low blood sugar). The pharmacist did not feel pharmacy was responsible for notifying the physician of medication refusals and nursing should be making the medical provider aware of medication refusals. During an interview on 6/27/2024 at 3:26 PM Nurse Practitioner #22 stated refusal of medications should be communicated to medical by nursing. Medical should know about refusals because they would need to assess the resident or make changes to medications. If a resident was ordered heparin and not receiving it, it could increase the risk for blood clots. If insulin or finger sticks were not being administered, it was clinically important to prevent hypoglycemia or hyperglycemia. During an interview on 6/28/2024 at 9:42 AM the Medical Director stated the medication regimen review should look at medications for reasonability, clinical indication, and make sure that levels are obtained as needed. They were not sure if the pharmacist looked at the medication administration record. Medications not being received should be reported to the medical provider. They were not aware Resident #147 had not been receiving medications as ordered. Not receiving heparin could lead to stroke, pulmonary embolism, or blood clots. The risk for not receiving insulin as ordered was out of control blood sugars. If medications were ordered, they should be given. 3) Resident #37 had diagnoses including diabetic neuropathy (nerve damage) and chronic venous insufficiency (damaged veins that can cause inflammation). The 5/29/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, frequently felt down, depressed, or helpless, had frequent trouble falling or staying asleep, felt bad about themself, had trouble concentrating, and had thoughts they would be better off dead, or of hurting themself in some way. The resident received a scheduled pain medication regime, received as needed pain medication, had almost constant pain that made it hard for them to sleep at night. and the pain constantly limited their day-to-day activities. The resident's worst pain was a 10 (0-10 pain scale with 10 being the highest pain level). Pain was triggered as a care area with a care plan. The Comprehensive Care Plan initiated 9/29/2022 documented the resident had an alteration in comfort related to neuropathy, back pain, and intermittent claudication (muscle pain from poor blood flow). Interventions included administer medications as ordered, report to the nurse resident complaints of pain or requests for pain treatment, notify physician if interventions were unsuccessful of if current complaint is a significant change from the resident's experience with pain, monitor for signs and symptoms of pain, if resident appears to be in pain utilize appropriate non-pharmacological interventions. Interventions were revised on 5/30/2024 and included evaluate effectiveness of pain intervention, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, and observe for new onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness, and falls, and report occurrences to the physician. Physician orders documented: - on 5/22/2024 pain evaluation every shift, record pain on a 0-10 scale. - on 5/22/2024 Lyrica oral capsule 100 milligrams, give 1 capsule every 12 hours for neuropathy, maximum daily dose 2 capsules. The 6/2024 Medication Administration Record documented Lyrica oral capsule 100 milligrams, give 1 capsule by mouth every 12 hours for neuropathy at 9:00AM and 8:00 PM. - on 6/21/2024 Lyrica was last administered at 9:00 PM by Licensed Practical Nurse #86. - On 6/22/2024 Lyrica was documented as a 9 (other/see nurse notes) at 9:00 AM Licensed Practical Nurse #53, and at 8:00 PM by Licensed Practical Nurse #28 - On 6/23/2024 Lyrica was documented as a 9 at 9:00 AM by Licensed Practical Nurse #87, and at 8:00 PM by Licensed Practical Nurse - On 6/24/2024 Lyrica was documented as a 9 at 9:00 AM by Licensed Practical Nurse #28 and documented as administered at 8:00 PM by Licensed Practical Nurse #28. Nursing notes documented: - on 6/22/2024 at 10:37 AM by Licensed Practical Nurse #53 Supervisor aware that Lyrica needs to be ordered, not available in Pyxis (an automated medication dispensing system). - on 6/22/2024 at 8:58 PM by Licensed Practical Nurse #28 the Lyrica was on order, awaiting pharmacy to deliver. - on 6/23/2024 at 8:18 AM by Licensed Practical Nurse #87 the Lyrica was not on hand. - on 6/23/2024 at 8:44 PM by Licensed Practical Nurse #28 the Lyrica was on order, waiting for the pharmacy to deliver. - on 6/24/2024 at 9:14 AM by Licensed Practical Nurse #28 the Lyrica was on order, waiting for the pharmacy to deliver. The nursing notes did not document the resident's pain level. The 6/2024 Treatment Administration Record documented pain evaluation every shift. The residents pain level was documented: - on 6/22/2024 at an 8 for the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts; and a 0 for the 11:00PM-7:00 AM shift. - on 6/23/2024 at a 0 for the 7:00 AM-3:00 PM shift; an 8 for the 3:00 PM-11:00 PM shift; and a 0 for the 11:00 PM-7:00 AM shift. - on 6/24/2024 at a 7 for the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. There was no documented evidence the provider was notified Lyrica was not administered to the resident. The 6/24/2024 at 3:49 PM progress note transcribed by Nurse Practitioner #22 and signed by the Medical Director documented the resident's pain was a 7 on 6/24/2024 at 10:46 PM. The resident had chronic lower extremity pain. The resident did not feel their pain was fully compensated on oxycodone (an opioid pain reliever) every 12 hours and the oxycodone was increased to every 8 hours. The resident stated their neuropathic pain in the lower extremities was worse. The resident did not think they received their Lyrica that morning. They spoke with the Nurse Manager who would check on the administration of the resident's Lyrica. During an interview on 6/24/2024 at 4:44 PM, Resident #37 stated they had not received their Lyrica since 6/21/2024. They stated the Lyrica and oxycodone worked well together. They stated facility staff informed them they had ordered Lyrica last Monday 6/17/2024. They stated acetaminophen did not touch their pain. During an interview on 6/25/2024 at 9:32 AM, Licensed Practical Nurse #28 stated Resident #37 had consistent pain. The resident ran out of scheduled Lyrica on 6/21/2024 and they ordered the medication through the pharmacy. On 6/22/2024, they notified the supervisor that the resident did not have medication available. Resident #37 did not receive their Lyrica on 6/22/24, 6/23/24, and 6/24/24 morning dose. During an interview on 6/25/2024 at 9:32 AM, Licensed Practical Nurse #28 stated the resident was in constant pain. The resident's Lyrica ran out on 6/21/2024. The Licensed Practical Nurse Unit Manager #2 called the pharmacy on 6/21/2024. Licensed practical nurses notified the supervisor if medications were not given to a resident. They notified the supervisor on 6/22/2024 that the Lyrica was not there, and they would contact the provider directly. The policy in the facility was for the licensed practical nurse to call the supervisor and then the supervisor would notify the provider. During an interview on 6/25/2024 at 9:54 AM, Licensed Practical Nurse Unit Manager #2 stated the resident constantly had pain in their lower back and legs from diabetic pain, wound pain, and vascular pain. The resident's Lyrica was low on 6/21/2024 so it was ordered. The medication was supposed to be on the 4:00 PM pharmacy run on 6/21/2024. They did not work the weekend and were informed on 6/24/2024 that they medication still had not come in. The medication nurse was responsible for notifying the supervisor if medications were refused or not available and document when a supervisor was notified. They stated all nurses had access to the pyxis system. During an interview on 6/25/2024 at 10:31 AM, Nurse Practitioner #22 stated that any missed dose of medication was unacceptable. They expected to be notified about missed doses but was not. The nursing staff did not inform them about the missed doses of Lyrica. The resident notified them on 6/24/2024 when the resident pulled them aside to tell them they did not feel well. During an interview on 7/8/2024, at 1:47 PM, Licensed Practical Nurse #28 stated the supervisor was notified and informed them the Lyrica was not available. They stated during the 8:00 PM medication pass on both 6/22/2024 and 6/23/2024, they notified the supervisor the medication was unavailable. They were unsure which nursing supervisor they spoke with on 6/23/2024. They stated they spoke with the Licensed Practical Nurse Unit Manager on 6/24/2024 who spoke with the pharmacy. They stated they had never received training on the Pyxis system (automated medication dispenser). During an interview on 7/9/2024 at 10:27 AM, Registered Nurse #94 stated they worked on both 6/22/2024 and 6/23/2024. They stated the first thing to do if a scheduled medication was not available was to check the Pyxis and call the pharmacy to see if an emergency run could be done. They would then call the provider to get directions on how to proceed until the medication was available. It was important for residents to receive medications as ordered. It is important that pain medications were given as pain can be a contributing factor that affects several areas of life, from therapy to sleep. They did not recall being notified that the resident's Lyrica was not available. The registered nurse supervisor or Unit Manager would be responsible for notifying the provider. During an interview on 7/9/2024 at 1:47 PM, the Medical Director stated if a resident did not get their narcotic medication, they would expect to be notified. 10NYCRR 415.3(e)(2)(ii)(b,c ) 44838 48895

Based on observation, record review, and interview during the extended recertification and abbreviated (NY00335306, NY00334736, NY00331600, NY00335937, NY00337529, NY00340292, NY00340725, and NY00335379) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure services provided met the professional standards of quality in 5 of 5 areas (pressure ulcers, medication administration, respiratory care, activities of daily living, and laboratory testing notifications). Specifically, medication administration was not completed in accordance with accepted standards of clinical practice (see F 554); provider notification was not completed for residents with significant changes in condition (see F 580); oral care and feeding assistance was not completed as ordered or planned (see F 677); pressure ulcer prevention services were not completed as ordered (see F 686); splints were not applied as ordered (see F 688); recommendations for appetite stimulant were not discussed with the provider for a resident with significant weight loss (see F 692); respiratory equipment was not maintained appropriately (see F 695); residents had unresolved pain that affected their daily functional abilities (see F 697); medically related social services were not provided to residents with significant mental health diagnoses (see F 745); and routine laboratory testing and the results were not reviewed by facility staff in a timely manner, and the medical provider was not notified in a timely manner of the abnormal lab results (see F 773) . Additionally, the inability to meet the professional standards led to the outcome of abuse and neglect (see F 600). Findings include: The New York State Education Law Article 139, Section 6902 documented the practice of the profession of nursing included the executing of medical regimens prescribed by a licensed physician. The facility policy, Charting and Documentation dated 10/2019, documented the following information was to be in the resident's record: objective observations; medication administered; treatments or services performed; changes in resident's condition, events, incidents, or accidents involving the resident; and progress toward or changes in the care plan goals. Self-Administration of Medication (F554): - Resident #21 was observed with ammonium lactate 12% cream, pink liquid stomach relief, and bottle of surgical scrub in their room. - Resident #64 was observed with 3 pills at the bedside on 6/4/2024, and a pill on the floor on 6/7/2024. - Resident #72 was observed with eye drops at bedside. - Resident #207 was observed with 1 pill on the bedside table. - Resident #239 was not observed by nursing staff to ensure medication administration was complete for a controlled substance. - All 5 residents did not have documented evidence they were assessed to determine their ability to safely self-administer their medications or of a physician order for self-administration of medication. The facility's failure to ensure residents' medications were safely administered placed all 248 residents at risk for serious harm or serious adverse outcomes. This resulted in Immediate Jeopardy to resident health and safety. Physician Notification for Change in Condition (F580): - Resident #37 did not receive their Lyrica from the day shift (7:00 AM-3:00 PM) of 6/22/2024 until day shift of 6/24/2024 due to the facility not having the resident's ordered medication and the provider was not notified. This resulted in putting residents who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care. - Resident #147 refused heparin, insulin, and labs as ordered for a period of 6 months, the medical provider was not notified and there was not an assessment by the provider. - Resident #153 had a low blood glucose level that was reported to the facility by the lab on 6/22/2024 and the provider was not notified. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety. - Resident #528 had a change in condition and was not assessed by a qualified professional when the change was noted, the medical provider was not notified, and the resident's representative was not notified. Subsequently, the resident was hospitalized with severe dehydration. This resulted in harm to Residents #528 and #37 that was not immediate jeopardy. Activities of Daily Living (F677): - Resident #154 did not receive oral hygiene as ordered. - Resident #226 did not receive assistance with eating as care planned. Pressure Ulcer Services (F686): - Resident #826 was readmitted from the hospital with pressure injuries of the sacrum and heel, the areas were not assessed by a qualified professional, and there were no treatments provided for the areas. The resident was re-hospitalized on two subsequent occasions, had pressure injuries of the sacrum and heels, the areas were not assessed timely by a qualified professional or provided with treatments following readmission. - Resident # 271 had orders for pressure relief boots to be worn while in bed and the boots were not applied. Subsequently, the resident developed a deep tissue injury (localized area of purple/maroon discolored intact skin due to damage of underlying tissue) area to their right heel. Additionally, there were wound care recommendations for a wheelchair cushion evaluation and for the resident's brief to be left open to air that were not implemented. - Resident #222 and #265 both had documented pressure ulcers with orders for daily dressing changes that were not completed as ordered. This resulted in harm and Substandard Quality of Care to Residents #271 and #826 that was not immediate jeopardy. Limited Range of Motion (F688): - Resident #64 did not have bilateral hand splints in place as ordered and care planned. Maintaining Acceptable Parameters of Nutritional Status (F692): - Resident #133 had a significant weight loss and recommendations for an appetite stimulant were not discussed with the medical provider. Respiratory Care (F695): - Resident #64's did not receive the appropriate Bilevel Positive Airway Pressure (mechanical non-invasive ventilator for breathing assistance) mask. Pain Management (F697) -Resident #28's physician ordered pain cream was not administered as ordered and was documented as administered. -Resident #37 did not receive Lyrica (used to treat nerve and muscle pain) as ordered for 3 days; -Resident #64 was not aware of an as needed order for acetaminophen (pain reliever) and was not offered the medication when in pain. Subsequently, Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life. This placed all residents with pain, who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care. Medically Related Social Services (F745): - Resident #41 did not have person-centered mental health interventions, licensed psychologist's recommendations were not implemented into the resident's plan of care. There were no documented social services follow up with the resident following their behaviors. - Resident #126 did not have person-centered mental health interventions for their behaviors or refusals of care and medications. There were no documented social services follow up with the resident following their behaviors. - Resident #153's licensed psychologist's recommendations were not implemented into the resident's plan of care, a recommendation for a traumatic brain injury program was not investigated, and recommendations to continue psychotherapy were not followed. There were no documented social services follow up with the resident following their behaviors. - Resident #235 had behaviors of taking things off the nurses' cart and throwing them leading up to an episode of threatening staff with scissors, requiring police intervention and hospitalization for the resident. There were no documented interventions from social services and the resident did not have person-centered interventions for their history of delusions and taking/throwing things off the nurses' cart. - Resident #250 did not have person-centered mental health interventions for their behavioral symptoms. - This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care. Laboratory Services Notification of Results (F773): - Resident #529 had routine laboratory testing and the results were not reviewed by facility staff in a timely manner, and the medical provider was not notified in a timely manner of the abnormal lab results. Subsequently, the resident was hospitalized 3 days later with pneumonia and dehydration. This resulted in harm to Resident #529 that was not immediate jeopardy. - Resident #153 had a critically low blood glucose (blood sugar) of 49 milligrams/deciliter and the provider was not notified in a timely manner and the resident was not assessed. - Resident #260 had a high international normalized ratio (INR, used to determine blood clotting times for residents on anticoagulant therapy) and the provider was not notified timely, and the resident was not assessed. - This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety. During a telephone interview on 6/10/2024 at 10:05 AM, Nurse Practitioner #16 stated if they ordered acute labs for a resident, they typically followed up the next day to review the results. If routine scheduled labs were completed, they expected nursing to notify them as soon as possible of any alterations. Lab results such as a high white blood cell count and elevated blood urea nitrogen were labs they wanted to be notified about. They stated they believed they did not work on 2/16/2024 and did not review the resident's labs until after the resident was discharged to the hospital. If they had known the resident's white blood cell count was high, they would have intervened and ordered a chest x-ray and/or urinalysis (often used to check for urinary tract infections). For the elevated blood urea nitrogen, they would have ordered extra hydration (fluids) by mouth or intravenously (through a vein). Earlier intervention could have resulted in a different outcome for the resident. During an interview on 6/10/2024 at 11:50 AM, Licensed Practical Nurse #34 stated Resident #28 had not yet received their 9:00 AM dose of pain relief gel. The nurse stated they signed off for all medications in the morning and did treatments after they finished the oral medications. They made a list for tasks they signed off on and had to come back to complete, including application of cream and dressing changes. They stated they should not sign off on medications they did not give. If the resident refused after they already signed off, they would strike out the entry. During an interview on 6/10/2024 at 12:35 PM, Certified Nurse Aide #40 stated the resident had dementia and required assistance with their meals. They stated the resident was on their assignment and they did not help the resident. They had a lot of residents that needed assistance, and they needed more staff to help. During an interview on 6/10/2024 at 12:54 PM, Licensed Practical Nurse #30 stated they were supposed to complete a dressing change for Resident #222 but did not get to complete it. They made a list of items they signed off for in the electronic medical record to make sure they completed the tasks, and their actions matched what they previously charted. If they were unable to complete a task on their list, they tried to go back into the electronic medical record and edit their entry, but they did not always have time. During an interview on 6/11/2024 at 9:18 AM, Nurse Practitioner #22 stated recommended interventions should have been brought to the provider's attention after the interdisciplinary team meeting in May 2024. The medical provider was not notified in a timely manner of the significant weight loss and recommendations for an appetite stimulant. During an interview on 6/11/2024 at 11:54 AM, Assistant Director of Nursing #24 stated medications should not be left at the bedside. Documentation should not be completed before the treatment was done, as the resident could refuse, leave the unit, or staff could forget or get too busy to come back later. During an interview on 6/12/2024 at 10:00 AM, Licensed Practical Nurse #33 stated they were trained to complete all oral medications and sign off on all the medications. They would write down the medications and tasks that needed to be completed based on what they signed off on as completed. If a resident refused or was not in their room, they would strike out the entry and write a progress note. They stated it was not a good idea to sign off on things they had not yet completed, because the sign off documents it as complete. During an interview on 6/12/2024 at 12:29 PM, the Nurse Educator stated they discussed medication administration at orientation, and nurses should document that medications were administered right after being given. They did not train staff to sign for things that were not done, that was unethical. Signing for something that was not done was falsification of documentation, and the nurse did not do it. The expectation was that all medications were signed for at the point of care. If something was not done, it should not be signed for. They expected to see dressing changes done the day they were dated, and the dates should be done as ordered. Respiratory equipment should be placed properly, if not the resident could have problems with breathing when sleeping. During an interview on 6/12/2024 at 12:29 PM, the Director of Nursing stated it was expected that the staff completed treatments as ordered, they were medically necessary for the resident and the provider deemed them appropriate. Staff should not sign off on tasks ahead of time, but if they had and the resident refused, or they were unable to complete the ordered treatment they should edit their documentation to reflect that. They should also let the supervisor know they were unable to complete the required task. Signing off on tasks before completing them, did not meet the professional standard for care. Medications should not be signed off as completed before the medication was administered to the resident. Signing off on medications before administration did not meet the professional standard. It was expected that splints were placed on residents as ordered. The electronic medical record should not be sign off without the splints being placed on the resident. The signature documented the task was complete when it was not. If the task was signed as completed and the resident refused, the documentation should reflect the actual care of the resident. Signing off on splint placement and not placing the splint did not meet the professional standard. It was expected that residents would have their teeth brushed as ordered and should not be signed for if it was not completed. Signing off the task of oral hygiene without completing it, did not meet the professional standard. During an interview on 6/25/2024 at 9:09 AM Registered Nurse #89 stated on 6/21/2024 at 5:26 PM they received a call from the lab stating Resident #153 had a glucose of 49 milligrams/deciliter. They were completing an admission assessment on another resident at the time of the call, but they called the unit to check on Resident #153. They were told the resident had taken all their medications. They should have called a medical provider to let them know the resident had a critical result of 49 milligrams/deciliter to get further orders. 415.11(c)(3)(i) 49448

44838 Based on observations, record review, and interviews during the extended recertification and abbreviated (NY00335306) surveys conducted 6/4/2024-7/11/2024, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 7 residents (Residents #222, #265, #271, and #826) reviewed. Specifically, Resident #826 had pressure injuries that were not assessed, and was not provided treatments to promote healing. Subsequently, Resident #826 was admitted to the hospital with a chronic sacral osteomyelitis (inflammation of bone tissue related to infection) with overlying cellulitis (skin infection). The resident underwent surgical debridement (removal of dead tissue), was in a great deal of pain, was unable to sit, which hindered their ability to attend dialysis while in the hospital. Resident #271 developed a deep tissue injury after orders to aid in the prevention of pressure injuries were not followed. Resident #271 had orders for pressure relief boots to be worn while in bed, which were not applied, in addition to other wound care recommendations that were not completed. Resident #265's pressure ulcer treatments were not administered daily as ordered. Resident #222 pressure ulcer treatment and off-loading heel boots were not administered daily as ordered. This resulted in harm and Substandard Quality of Care to Residents #271 and # 826 that was not immediate jeopardy. Findings include: The facility policy, Risk and Skin Assessments, last revised 1/2021, documented prevention of pressure ulcers required early identification of at risk residents and the implementation of prevention strategies. Skin assessments were done by a licensed nurse weekly. The facility policy, Skin and Pressure Injury Prevention, revised 3/2023, documented staff would conduct a comprehensive skin assessment upon admission /re-admission including skin integrity, any evidence of existing or developing pressure injuries, or other skin abnormalities or areas of impaired integrity. The risk assessment should be conducted as soon as possible after admission. Once the assessment was conducted and risk factors identified and characterized, the resident-centered care plan would be created. 1) Resident #826 had diagnoses including prostate cancer, bone cancer, and dependance on renal dialysis (a process that filters blood during kidney failure). The 6/8/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, was at risk for pressure ulcers, and did not have unhealed pressure ulcers. The 6/1/2023 admission evaluation completed by Registered Nurse Unit Manager #23 documented the resident had padded dressings to both heels and no other open areas were noted. The resident had a Braden score of 15, (a scale that determines risk for development of pressure ulcers) and was at low risk. The comprehensive care plan initiated 6/1/2023 documented the resident was at risk for pressure injury development related to immobility. Interventions included apply moisturizer as needed, monitor nutritional status, and monitor and report changes in skin status. The 6/2023 Documentation Survey Report (daily care log) documented to off load heels with pillows or boots as tolerated and turn and reposition every 2 to 4 hours as indicated and as needed. The 6/9/2023 at 9:17 AM Registered Nurse #1 (former Assistant Director of Nursing) progress note documented the resident went to a medical appointment, was sent to the hospital from the appointment due to fatigue. The resident was admitted to the hospital. The 6/16/2023 hospital discharge summary documented the resident had an unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) to the sacral region and a deep tissue injury (discolored skin due to damage of underlying soft tissue from pressure or shear) to the right heel. Discharge instructions included follow up with the wound care center. The 6/16/2023 Nursing Admission Evaluation completed by the Assistant Director of Nursing #1 documented the resident had 5 wounds: a bicep fistula, a chest port site, deep tissue injury to both heels, and an unstageable pressure injury to their sacrum. The left heel measured 3 centimeters x 4 centimeters, and the right heel measured 4 centimeters x 2 centimeters and treatments were in place. The heel wounds were noted to have absorbent pads. There was no documentation of wound measurements or a treatment for the unstageable pressure injury on the sacrum. There were no documented treatment orders for the resident's deep tissue injury as referenced in the Assistant Director of Nursing #1's 6/16/2023 Admission Evaluation. The comprehensive care plan initiated 6/19/2023 documented the resident was at risk for impaired skin integrity related to fragile skin, impaired mobility, and renal disease. Interventions included apply protective/preventive skin care, minimize extended exposure of skin to moisture with frequent incontinence care and prompt removal of wet clothing/bedding as needed, and report any signs of deterioration or significant change to area of impairment. The care plan did not address the unstageable pressure injury to the sacrum. The 6/19/2023 Nurse Practitioner #6 progress note documented they saw the resident for an admission evaluation. There was no documentation related to the pressure injuries on the resident's sacrum or heels. The 6/20/2023 Nurse Practitioner #6 progress note documented the resident was seen for a follow up visit related to not feeling well. The resident had severe pain in their back. The review of systems included skin impairments of unstageable sacral ulcer and heel ulcers (not specified) to both heels. There were no recommendations or orders for treatments documented. The 6/20/2023 physician order documented weekly skin evaluation every Tuesday on the day shift. The 6/2023 Treatment Administration record did not include treatments for the heel deep tissue injuries or the unstageable sacral ulcer. The record documented the weekly skin evaluation was completed on 6/20/2023 and 6/27/2023. There was no documented evidence of skin impairments to the sacrum or heels from the skin evaluations. There was no documented evidence of wound care or a physician's order for the sacral or heel wounds from 6/16/2023 to 6/28/2023 (when the resident was re-hospitalized ). There was no documented referral to wound care center. A 6/28/2023 at 3:07 PM Licensed Practical Nurse Unit Manager #2 progress note documented the resident went for a cancer care appointment and was sent to the emergency room . The 6/28/2023 hospital History and Physical documented the resident's diagnoses included deep tissue injury to the right heel and an unstageable pressure injury to the sacral region. The comprehensive care plan initiated 7/20/2023 documented the resident had an alteration in skin integrity and had an actual pressure injury to the sacrum, Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). Interventions included evaluate wound weekly and as needed, document measurements, appearance, drainage, and surrounding tissue, monitor for changes, nutritional and therapy evaluation. (The comprehensive care plan was initiated before the resident returned from a 6/28/2023-7/21/2023 hospital stay). The 7/21/2023 hospital After Visit Summary documented the resident had deep tissue injury to both heels and an unstageable pressure injury on the sacrum. The 7/21/2023 Nursing Admission Evaluation completed by Licensed Practical Nurse Manager #2 documented the resident had no skin impairments. There was no documented evidence of an assessment by a qualified professional for the pressure injuries present to the heels or sacrum upon readmission from the hospital. There was no documented evidence of treatments for the pressure injury on the sacrum from 7/21/2023 to 7/25/2023. There was no documented evidence of treatments for the heels through 7/31/2023 (when the resident was re-hospitalized ). Physician orders documented: - consultation for evaluation and treatment for sacrum pressure ulcer that the resident came with, start date 7/25/2023. - Sacrum, cleanse wound with wound cleanser, pat dry with gauze, apply medical grade honey (wound treatment) and calcium alginate (wound treatment that absorbs drainage) combination to wound bed, cover with an island bordered dressing every night shift and as needed, start date 7/25/2023. - Low air loss mattress (specialty mattress for pressure reduction), check setting closest to the resident's current weight and mattress functionality every shift for monitoring and as needed, start date 7/25/2023. There was no documented order for a treatment for the deep tissue injuries on the resident's heels. A 7/25/2023 Wound Consultant Physician #3's progress note documented the resident was referred for an initial evaluation and treatment for a wound on the sacrum. The resident had an unstageable sacral wound, due to pressure, present for greater than 30 days, that measured 2.5 centimeters long, 2.5 centimeters wide, and 0.3 centimeters deep. The treatment included medical grade honey and calcium alginate and recommendations to turn and position every 1 to 2 hours if able, off-load wound, limit sitting to 60 minutes, a pressure-relieving mattress, and vitamin and mineral supplements. There was no documented evidence of referral or evaluation for the wounds on the resident's heels. The 7/31/2023 physician #11 progress note documented the resident was sent to the hospital due to low oxygen and concerns with their ability to attend dialysis. The progress note did not include why the resident had limited ability to attend dialysis. The 8/10/2023 hospital discharge summary documented the resident was admitted with a chronic sacral osteomyelitis (inflammation of bone tissue related to infection) with overlying cellulitis (skin infection). The resident underwent surgical debridement (removal of damaged tissue), was in a great deal of pain, was unable to sit, which hindered their ability to attend dialysis. The 8/10/2023 hospital discharge instructions documented wound care to the sacrum, cleanse with normal saline moistened gauze, apply collagenase (ointment that removes dead tissue) nickel thick to slough (dead tissue) areas of wound, cover entire wound with a single layer of antimicrobial absorbent dressing and apply sacral bordered dressing, change daily and as needed. Wound care to heels, cleanse with foam cleanser and apply protective ointment to help soften heels once daily. The 8/10/2023 Nursing Admission Evaluation completed by Licensed Practical Nurse #7 documented the resident had one pressure wound to the coccyx (sacrum). There was no documentation related to the pressure areas to the heels or treatment to the sacral wound. The 8/10/2023 telehealth medical provider readmission note documented the medication was reconciled with the registered nurse, and the resident would need a comprehensive exam and admission by the primary care team. There was no documentation related to the resident's wounds or treatments. The 8/11/2023 physician order documented apply skin prep (protective barrier) to bilateral (both) heels daily, offload heels every day shift, start date 8/12/2023. There was no documented evidence of assessment by a qualified professional or treatment of the wound on the resident's sacrum from 8/10/2023 to 8/15/2023. The 8/16/2023 Wound Consultant Physician #3's progress note documented the resident was seen for wounds on the sacrum, left heel, and right heel. The wound on the sacrum measured 3 centimeters long by 2 centimeters wide, and 0.5 centimeters deep. The wound was improved based on decreased necrotic (dead) tissue and revealed it was now a Stage 4 pressure injury. The treatment included alginate calcium (absorbent wound treatment), gauze island bordered dressing, and recommendations to turn and position every 1 to 2 hours if able, off-load wound, limit sitting to 60 minutes, a pressure-relieving mattress, and vitamin and mineral supplements. The areas on the heels were fully covered with dead tissue. Treatment included daily skin prep to the heels with recommendations for off-loading the wound and floating the heels in bed. The 8/16/2023 physician order documented for the sacrum, cleanse wound with wound cleanser, apply calcium alginate to wound bed, cover with island bordered gauze. During an interview on 6/10/2024 at 11:12 AM the former Assistant Director of Nursing #1 stated skin assessments were completed by a registered nurse when residents were admitted or readmitted . The assessments should be completed upon admission or within 24 hours. If skin impairments were noted, the physician should be notified for treatment orders. Treatment for Resident #826's unstageable pressure injury on the sacrum and deep tissue injury on the heel should have been initiated immediately with referral to the wound team to be seen on the next rounds. The identified areas should have been assessed weekly on wound rounds and observed with each treatment. They could not recall Resident #826 or the reasons there was no wound treatment documented following their admission on 6/16/2023. They stated they covered multiple units and completed admission assessments. The Unit Manager was responsible to review the hospital documentation, orders, and make any referrals needed, including wound care. Treatments were not initiated timely from 6/16/2023 until the resident was hospitalized on [DATE]. During an interview on 6/10/2024 at 12:10 PM Licensed Practical Nurse Manager #2 stated licensed practical nurses could complete skin evaluations upon admission. If any skin impairments were noted, a registered nurse should be notified to complete an assessment and initiate a treatment. The Unit Manager was responsible for new admissions, referrals, and reviewing the hospital documentation. Licensed Practical Nurse Manager #2 could not recall if they saw the 6/16/2023 hospital discharge summary that noted wound care follow up. The resident should have had treatment initiated immediately for the sacral wound and heel, in addition to a referral to the wound care team. When Resident #826 was readmitted on [DATE], Licensed Practical Nurse Manager #2 recalled they completed the skin evaluation and documented no skin impairments. They stated it may have been related to not being able to view the resident's back side or heels due to the resident being in pain. They could not recall if they notified a registered nurse to complete the assessment or if the hospital paperwork included information about the pressure injuries. The treatment was initiated on 7/25/2023, and this was not timely, as it should have been done immediately. When the resident was hospitalized again and readmitted on [DATE], the treatment for the sacrum should have resumed immediately and was not. Licensed Practical Nurse Manager #2 was unaware of the reason for the delay in the treatment order for the sacrum. During an interview on 6/10/2024 at 1:02 PM Wound Consultant Physician #3 stated the wound care nurses, Unit Managers, or registered nurses made referrals to the wound physician. They rounded weekly, and a registered nurse would assess the wound and initiate treatment until the wound physician saw the resident. It was their understanding that a registered nurse assessed all newly admitted residents for skin impairments. Any new skin impairments should be assessed and treated immediately. The wound physician first saw Resident #826 on 7/25/2023 and was unaware of their 6/16/2023 admission with the unstageable pressure area and deep tissue injury on the heel. When the resident was referred on 7/25/2023, staff identified the sacrum as the area of focus and the physician was unaware of any issues with the heel. The treatments for the sacrum and heels were not initiated timely. When the resident was readmitted on [DATE], the registered nurse should have assessed the sacral area and implemented the treatment on the hospital discharge instructions. If there were no hospital orders, the registered nurse could have called the wound care physician for a treatment order or revert to the prior treatment. The resident should have had treatment initiated immediately upon return from the hospital. 2) Resident #271 had diagnoses of cerebral infarction (stroke), right sided hemiplegia (paralysis of one side of the body), and diabetes. The 4/19/2024 Minimum Data Set assessment documented the resident had intact cognition, functional limitation on one side of the upper and lower extremities, was dependent for activities of daily living, was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, did not have any unhealed pressure ulcers, and had pressure reducing devices for their chair and bed. The comprehensive care plan dated 4/12/2024 documented the resident was at risk for pressure injury development related to diabetes, impaired mobility, and incontinence. Interventions included minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp sheets and clothing, and heel protection-offload with pillows or boots as tolerated. The 6/5/2024 Wound Care Physician #3 evaluation documented the resident had wounds on their right plantar (bottom) first toe, right posterior (back) thigh, and left buttock. The plan of care recommendations for the right toe were cleanse with wound cleanser at time of dressing change; off-load wound; reposition per facility protocol; and float heels in bed. For the left buttock and right posterior thigh moisture associated skin damage recommendations were turn side to side in bed every 1-2 hours if able; upgrade offloading chair cushion: evaluate cushion, was very thin for bariatric size patient, and leave brief open in bed and ensure brief was properly sized. There was no documented evidence the resident's offloading chair cushion was evaluated or the resident's incontinence brief was to be left open while in bed was added to the care planned interventions. The 6/12/2024 Wound Care Physician #3 evaluation documented progress of wound healing for the right plantar first toe healing at goal, right posterior thigh improved, and left buttock exacerbated (worsened) due to increased maceration (exposure to moisture). There was a new unstageable deep tissue injury on the right heel with the etiology (cause) of pressure. The area measured 5 centimeters x 6 centimeters with intact purple, maroon discolored skin. The treatment plan was skin prep (protectant) daily X 30 days, with recommendations for off-loading wound, reposition per facility protocol, and pressure off loading boot. Physician orders dated 6/5/2024 documented zinc oxide (skin protectant) to buttocks every shift. The June 2024 Certified Nurse Aide task documentation included heel(s) protection: offload with pillows or boots as tolerated and was documented as completed 6/1/2024- 6/9/2024 all shifts. The resident was observed and interviewed at the following times: - on 6/4/2024 at 10:44 AM, sitting in their wheelchair. They stated they had sores on their bottom and felt it was from staying in the diaper too long, and in bed too long. They stated the cushion in their wheelchair felt deflated, and they needed an air mattress. - on 6/5/2024 at 9:20 AM, in bed wearing only a brief, with no protective boots on their feet or positioning devices for offloading. - on 6/6/2024 at 9:54 AM, in bed with only a brief on. They stated they had not been changed since before the shift change. They asked for their brief to be left open to dry areas out, but staff closed it anyway. The brief was observed taped tightly on both sides. There were no protective boots on their feet or positioning devices for offloading. - on 6/7/2024 at 9:33 AM, they stated the boots were only worn when they were sleeping. The thin gel cushion remained in the wheelchair seat and continued to be uncomfortable. The resident stated no one had offered them a new wheelchair cushion. - on 6/7/24 at 10:49 AM, Certified Nurse Aide #6 and Licensed Practical Nurse #62 provided peri- care. Zinc oxide was applied by the nurse to the open areas on the back of the right thigh and left buttock. The resident was dark skinned with pink open irritated areas present in the inner gluteal cleft on the left buttock and posterior right thigh. The resident had been incontinent of urine, their brief was changed, and staff stated there was no care plan that included to leave the brief open. The resident refused protective boots and asked to stay in bed due to an upset stomach. - on 6/10/2024 at 11:21 AM, in bed dressed and groomed. Their wheelchair remained with a thin gel cushion in the seat. The resident stated the cushion did not provide enough pressure relief and their bottom hurt when they were in their chair. - on 6/24/2024 at 1:11 PM, sitting in their wheelchair in the therapy gym, with non-skid socks on both feet, there was no padding present on the wheelchair pedals. - on 6/24/24 at 3:20 PM, in their room sitting in their wheelchair wearing non-skid socks on both feet. The wheelchair pedals remained uncovered. - on 6/24/24 at 4:20 PM, in their bed wearing only an incontinence brief and their left foot resting directly on the mattress. There were no pillows used for positioning or a protective boot in place. - on 6/25/24 at 8:39 AM, in bed wearing only an incontinence brief, eating breakfast, wearing a protective boot on the right foot and a non-skid sock on the left foot. There was no pillow used for positioning or to relieve pressure on the heel. During an interview on 6/5/2024 at 9:42 AM, Registered Nurse Unit Manager #23 stated certified nurse aides should let a nurse know of any changes to a residents' skin. They had not been notified that Resident #271 had moisture areas on their buttocks. The current interventions in place included to encourage the resident to get up out of bed, moisture barrier cream with care, and a request for a bed trapeze (to allow the resident to be able to reposition self independently) had been sent. During an interview on 6/7/2024 at 11:33 AM, Certified Nurse Aide # 60 stated resident care information was found in the care instructions including if protective boots were needed. Resident #271 preferred the boots only at night and did not usually wear them daily. They let the nurse know in the past about the resident not wearing boots. The resident often refused to allow staff to place pillows under their heels. The aide stated they should not be charting yes if the resident refused the intervention. Pillows and boots were important to prevent skin breakdown. They noticed the areas on the resident's bottom last week on the 3:00 PM-11:00 PM shift and told the nurse. They were not sure which nurse or which day. The resident had told them the areas were painful, and they thought it may have been from their incontinence brief. The resident received incontinence care when needed and was repositioned to prevent skin breakdown. They had been using barrier cream before the order for zinc oxide. During an interview on 6/7/2024 at 11:50 AM, Licensed Practical Nurse #62 stated certified nurse aides should report any changes in skin to the Nurse Manager. They stated a certified nurse aide told them last week that Resident #271 had some irritation to their buttocks. They told the Unit Manager and asked the wound care team if there were orders for the resident's bottom. The irritated areas could be from moisture. The resident would get up most days for therapy but liked to go back to bed. Prompt treatment was important to keep the areas from getting worse. The areas could turn into pressure or could get infected. Protective boots to protect heels from breakdown should be used when the resident was in bed and staff should notify a nurse if the resident refused. The resident could not move their right leg due to hemiplegia and that was an increased risk for pressure ulcers. During an interview on 6/7/2024 at 12:46 PM, Assistant Director of Nursing #24 stated if a heel protector was documented as yes, in place in the aide tasks of the electronic record, it meant it was on. If they were refused, it should be charted refused and the nurse should be told. Protective boots were important to prevent skin damage or breakdown. If a resident consistently refused, they would look for a different intervention. Resident #271 was at risk for pressure due to obesity, diabetes, and immobility. The resident had right sided hemiplegia and could not move their right side independently. The Assistant Director of Nursing #24 had not been made aware that the resident was refusing protective boots in bed. They were not made aware the resident had skin irritation to posterior thighs and buttocks until 6/5/2024 when they were seen by wound team. Prompt notification of skin issues was important to prevent further skin breakdown or new skin breakdown. In a follow up interview on 6/10/2024 at 4:13 PM, the Assistant Director of Nursing #24 stated recommendations and orders by the wound care team were entered by wound care nurses. The Nurse Manager and wound care team made sure recommendations were carried out. A recommendation for a wheelchair cushion evaluation should be done by physical therapy and should be communicated to physical therapy by the wound care nurse. The recommendation for evaluation of the chair cushion and incontinence briefs left open was not communicated. There was no therapy referral, and no care plan to leave the incontinence briefs open/untaped. The resident was at risk for pressure, and moisture associated skin damage could lead to additional pressure areas if interventions were not implemented. During an interview on 6/10/2024 at 4:28 PM, the Director of Rehabilitation stated wheelchair cushions were decided on by the interdisciplinary team based on resident assessment. A recommendation by wound care for a wheelchair cushion evaluation would need to be communicated to therapy either via email or verbally. They had not received a request for a wheelchair cushion evaluation for Resident #271. Resident #271 could not independently reposition themself due to hemiplegia and this increased their risk for altered skin integrity. If there was a recommendation for an evaluation it should have been communicated on the day it was recommended. During an interview on 6/11/2024 at 9:00 AM, Wound Care Registered Nurse #65 stated there had not been communication to the wound care team about Resident #271's skin irritation. Wound care orders and recommendations were communicated by putting the orders in the electronic health record. This was done by the wound care nurse. A wheelchair cushion evaluation was more of a recommendation and therapy would be notified via email or verbally. If the incontinence brief was to be left open it would be a care plan directive. Resident #271 was seen by wound care team on 6/5/2024, moisture associated skin damage was identified, and orders were placed for zinc oxide three times daily. The wound care nurse did not communicate any other recommendations from that consult. Updated interventions not being implemented could lead to pressure ulcers. They remembered discussing leaving the incontinence brief open but did not realize it was on the consult. They should have made sure all recommendations were communicated. During an interview on 6/11/2024 at 9:17 AM, Wound Care Physician #3 stated they were notified of the resident's need for a consult when impaired skin was noted. The consult was placed, and the resident was seen by the Registered Nurse prior to the consult to assess the need for treatments, actual pressure wounds, skin tears, and moisture associated skin damage present longer than 1 week and not healing. On 6/5/2024, during wound rounds the resident was asked if they had any other concerns and they mentioned their bottom. They stated the resident had moisture associated skin damage and trauma to their skin from the incontinence brief. They recommended treatment of zinc oxide, offloading of the wound, leaving the incontinence brief open, and a wheelchair cushion evaluation. These interventions would provide resolution or prevent worsening. The resident was at risk for pressure due to their immobility and should have offloading boots to prevent pressure on the feet. They were not aware the resident was not wearing the boots. During an interview on 6/27/2024 at 2:44 PM, the Assistant Director of Nursing #24 stated pressure interventions should be monitored by nurses, and offloading boots should be on the Treatment Administration Record. If a resident had a pressure area on their heel, they should have a pressure relieving device on at all times. The resident's wheelchair pedal was not padded, and their non-skid sock was not protective. The certified nurse aide had notified them on the 6/26/2024 that the resident refused the boot and the repositioning of the left heel. The recommendation did not specify a time or frequency, just that the foot should be offloaded as much as possible. The certified nurse aides should not be documenting heel offloading if it was not happening. During an interview on 6/27/2024 at 3:12 PM, Advanced Practice Registered Nurse #90 stated the resident was seen today in their wheelchair. They only had non-skid socks in place and there was no padding to the wheelchair pedals. The protective preventive pressure devices should always be in place because the resident was at risk for pressure due to limited mobility, morbid obesity, hemiplegia, and diabetes. During an interview on 6/28/2024 at 10:01 AM, Wound Care Licensed Practical Nurse #64 stated the resident had a deep tissue injury to their right heel and was seen by Wound Care Physician #3 on 6/12/2024. The physician recommended a pressure off-loading boot, with the heel always protected to promote healing and prevent worsening of wound. The pressure off loading boot should be in the care plan and communicated to staff to make sure interventions were in place. During an interview on 7/03/24 at 8:57 AM, Wound Care Physician #3 stated there should be a boot to the right heel to offload from pressure. It did not have to be a boot, but the heel had to be floated or on multiple pillows. Nurses should be checking and documenting the boots every shift. The pressure to the right heel was avoidable if interventions had been followed. The protective boots should be worn on both feet when the resident was in bed. 3) Resident #222 was admitted to the facility with diagnoses including osteomyelitis (inflammation of the bone caused by infection) of the sacral and sacrococcygeal (buttocks) region, and unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) of the left buttocks. The 3/22/2024 Minimum Data Set assessment documented the resident was cognitively intact, was dependent for bed mobility, transfers, and toileting, had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle pressure ulcer), received daily pressure ulcer care, applications of ointments/treatments other than to feet, had a pressure relieving device for the bed and chair, and did not reject care. The comprehensive care plan initiated 5/7/2023 documented the resident had an alteration in skin integrity and had an actual pressure injury Stage 4 to left ischium (back part of the pelvis) and a Stage 4 to the right heel. Interventions included dressings were monitored daily to ensure they were clean, dry, and intact; wounds were monitored daily for signs and symptoms of infection; weekly wound evaluations were completed; and any changes were documented and reported. The 5/28/2024 physician order documented to cleanse right heel with wound cleanser, pat dry with gauze, apply calcium a [TRUNCATED]

Based on record review and interviews during the extended recertification survey conducted 6/4/2024-7/11/2024 the facility's Medical Director did not ensure the coordination of medical care with interdisciplinary teams and implement and evaluate resident care policies to assure they reflected current professional standards. Specifically, the Medical Director failed to ensure that policies and procedures were developed and implemented to provide and monitor the delivery of care and services to residents in the areas of Self-administration of Medication (F 554), Pain Management (F 697), Laboratory Services/Notification of Results (F 773), and Provision of Medically Related Social Services (F 745), resulting in actual harm with potential for serious harm that was Immediate Jeopardy. Findings included: The undated facility Medical Director Job Description documented the Medical Director was a physician who served as the leader in the clinical setting or a health care facility. They were responsible for developing and implementing policies and procedures and best medical practices and coordinating care in the facility. They would oversee training and provide continuing education for their staff. The Medical Director would assure the medical facility was in line with all State, Federal and Local laws and should directly report any relevant information to the senior management of the facility. Additionally, the Medical Director would supervise the medical staff, review, and participate in quality assurance activities and directly oversee clinical safety and risk management. Resident Self Administration of Medication Refer to citation text under F554. Residents #21, #64, #72, #207, and #239 were not assessed to determine their ability to safely self-administer medications or had physician orders for self-administration of medication. The facility's failure to ensure residents' medications were safely administered placed all 248 residents at risk for serious harm or serious adverse outcomes. This resulted in Immediate Jeopardy to resident health and safety. Pain Management Refer to the citation text under F697. Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life. This placed all residents with pain, who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care. Provision of Medically Related Social Services Refer to citation text under F745. Residents #41, #126, #153, #235, and #250 were not provided medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care. Lab Services/Physician Order/Notification of Laboratory Results Refer to the citation text under F773. Residents #153, #260, and #529 had critical laboratory results that fell outside of the clinical reference range and the ordering physician was not promptly notified of the results. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety. During an interview on 7/9/2024 at 1:23 PM, Nurse Practitioner #22 stated they worked with the Medical Director for [AGE] years. The corporate administration did not include the providers in their administrative discussions. Prior to the corporate takeover of the facility the provider had some input into the admission and services for incoming residents, the day to day operations of the facility, and the needs of the residents. The providers used to be an integral part of the residents care and now they were not as involved. They had medical staff meetings with administrative staff, pharmacy, and all providers. The Medical Director oversaw the residents on 3 North. The policies were all corporate policies. During a telephone interview on 7/10/2024 at 2:25 PM, the Medical Director stated their responsibility was overseeing of physician services, ensuring the physicians were doing their mandated resident visits, and working closely with the Administration. They were not responsible for overseeing care of every resident in the facility, they were an attending physician with their own case load of residents. They currently did not have any input regarding facility policies. They used to have to sign off on the policies and procedures and was advised of and made aware of policy and procedure changes. They thought the facility was pulling most of the polices from the corporate level. They had gone to the Director of Nursing when they had concerns about policies and procedures and felt they were not being heard. They were unsure who to speak to beyond the Director of Nursing. The facility corporation was a complex system and ran things in layers and was filtered down to the facility. There were many people involved in who the facility would admit and how facility staff provided care to the residents. They stated they had not heard about the facility assessment and had no input into that document. In the past they would review residents and decide if the facility was able to accommodate and appropriately care for the new resident. The policies and procedures were corporate driven policies and they provided insight as requested but the corporation had their own way of doing things. During an interview on 7/11/2024 at 8:52 AM, the Administrator stated the Medical Director participated in the quality assurance meetings, the plan of correction, and rehospitalization s meeting. The policies come from the corporate team and the Medical Director should be aware of all the policies. 10 CRR NY 415.15(a)(1)(2)(3)

Based on observation, record review, and interview during the recertification and abbreviated (NY00324500) surveys conducted 11/27/2023-12/5/2023 the facility failed to ensure residents were free from neglect for 2 of 6 residents (Residents #18 and 31) reviewed. Specifically, Resident #18 had blood glucose levels that were outside of parameters and medical was not notified as ordered. The resident continued to have high blood glucose levels and was sent to the hospital for evaluation (Refer to F 684 Quality of Care). Resident #31 was not assisted with toileting per their care plan and as requested resulting in the resident being incontinent and being told to defecate in a brief (Refer to F 677 Activities of Daily Living Care). This resulted in actual harm of emotional distress from neglect of care to Resident #31 and hospitalization of Resident #18. Findings include: 1) Resident #31 had diagnoses of lumbar radiculopathy (a disease involving a spinal cord nerve root), cervical disc disorder (disorder of the bones in the neck), and depression. The 11/2/2023 Minimum Data Set assessment documented the resident was cognitively intact, did not refuse care, was incontinent of bladder and bowel, and required assistance of 2 for transfers and toileting. The 12/2023 resident care instructions documented assistance of 2 with a mechanical sit to stand for transfers, substantial assistance of 2 for toileting hygiene, provide a bedpan or bedside commode, and check resident every 2 hours and assist with toileting as needed. During an observation and interview on 11/28/2023 at 9:13 AM, Resident #31 was lying in bed putting their makeup on and stated they were waiting to get up due to having a medical appointment. The resident stated they used a mechanical sit to stand to get up. They stated they needed to use the bathroom during the overnight shift and was told by staff they were not getting the resident up at 1:00 AM. Staff told the resident to defecate in their brief. The resident stated they were having trouble with constipation, had received a lot of medication to assist with the problem and they needed to use the bathroom frequently. During an observation on 12/1/2023 at 10:50 AM, Resident #31 was lying in bed wearing a wet incontinence brief and there was a wet stain on their bed sheet. The resident stated they asked to get up and use the bathroom and were waiting for their certified nurse aide to come back but it was too late. The resident stated they had been waiting for 30 minutes and now their brief and sheet were wet. During an interview on 12/4/2023 at 11:31 AM, certified nurse aide #5 stated Resident #31 required assistance of 2 with a sit to stand lift for transfers and toileting needs. They stated the facility also had bed pans to offer the resident if they did not want to get out of bed or if it was late at night. Certified nurse aide #5 stated the resident was alert and oriented, could tell you when they needed to use the bathroom, and they were not offered the bed pan because they were coming back to get the resident up. Certified nurse aide #5 stated it would not be appropriate to tell the resident to defecate in their brief and it was undignified to do so. During an interview on 12/5/2023 at 10:47 AM, licensed practical nurse #13 stated the resident used a mechanical sit to stand for transfers and needed extensive assistance of 2 for toileting and they would expect staff to offer a bed pan to the resident if they did not want to get out of bed. They stated it would not be appropriate or dignified to ask the resident to defecate or urinate in their brief. 2) Resident #18 had diagnoses including diabetes with peripheral angiopathy (narrowing of arteries) and retinopathy (damage to blood vessels in the eye). The 10/16/2023 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, and received insulin injections 7 of 7 days. The comprehensive care plan initiated 8/16/2022 documented the resident had insulin dependent diabetes. Interventions included administer medications per physician orders and monitor blood glucose finger stick per physician orders. A physician order dated 10/26/2023 documented insulin glargine (long-acting insulin) inject 18 units subcutaneously in the morning for diabetes call physician if finger stick blood sugar was less than 70 milligrams/deciliter or greater than 300 milligrams/deciliter. The November 2023 medication administration record documented insulin glargine daily at 5:00 AM, notify physician for blood glucose less than 70 milligrams/deciliter or greater than 300 milligrams/deciliter. The following blood glucose results were documented: - on 11/3/2023 blood glucose 377 milligrams/deciliter - on 11/4/2023 blood glucose 484 milligrams/deciliter - on 11/5/2023 blood glucose 470 milligrams/deciliter - on 11/9/2023 blood glucose 395 milligrams/deciliter - on 11/10/2023 blood glucose 336 milligrams/deciliter - on 11/12/2023 blood glucose 380 milligrams/deciliter - on 11/13/2023 blood glucose 365 milligrams/deciliter Nursing progress notes dated 11/3/2023-11/13/2023 did not include documented evidence the physician was notified of the blood glucose results greater than 300 milligrams/deciliter. Nursing progress notes documented: - on 11/14/2023 at 6:40 AM licensed practical nurse # 83 documented the resident's blood glucose reading was HI, 18 units glargine given as ordered, rechecked blood glucose 30 minutes later, remained HI. Telehealth called and order received for 10 units of Novolog (rapid acting insulin) to be given one time for elevated blood sugar. - on 11/15/2023 at 1:30 PM licensed practical nurse #84 documented the resident's blood glucose was 448, the supervisor was made aware and order for lispro (rapid acting insulin) 10 units one time received. - on 11/18/2023 at 5:54 AM licensed practical nurse #85 documented the resident's blood sugar was HI, the nursing supervisor was notified, and the resident was transferred to the hospital. During an interview on 12/5/2023 at 11:13 AM, licensed practical nurse #86 stated they worked mostly evenings and overnights. Their job duties include passing medications, patient care, and staff would come to them with resident concerns. If a resident's blood sugar was out of the parameters, they would call let the supervisor know. The supervisor would call medical and let them know. They stated Resident #18 had blood sugar levels all over the map. They did not remember if they had to call the supervisor regarding Resident #18's elevated blood sugars. If the resident had an order to notify medical of blood sugars outside of certain parameters, it would be important to the resident to make sure that was done. During an interview on 12/5/23 at 12:37 PM, Assistant Director of Nursing # 48 stated they had previously been a night supervisor. Supervisors provided oversight, managed staffing, medical issues, and called providers if needed. The medication nurse would notify the supervisor of any issue on the floor, and the medical provider would be called by the supervisor, this included blood sugars out of parameters. Any issues would be documented on the 24-hour report. They stated an email shift report went to all Nurse Managers, Supervisors, Assistant Directors of Nursing, and the Director of Nursing. They did not remember receiving a phone call about Resident #18's blood glucose level on the morning of 11/5/2023. It was not documented that they were made aware or called medical. The resident's blood glucose was 470 at 4:21 AM per the electronic health record. The order stated medical should be called for a blood sugar less than 70 or greater than 300. If a resident's blood sugars were out of range, they could need more insulin. Medical should have been notified of those instances to make decisions based on correct information. Hypoglycemia and hyperglycemia both posed risks to the resident. During an interview on 12/5/23 at 12:52 PM Assistant Director of Nursing #3 stated there was a 24-hour report that contained any resident issues needing follow up. There was also a report via email by night supervisors, which contained resident issues such as falls, labs, and blood sugars out of parameters. They did not remember Resident #18's blood glucose levels being reported on the above dates in November. The medication nurse should have contacted the supervisor to call medical for the blood glucose levels above 300 and it should have been documented in progress notes. During an interview on 12/5/23 at 1:07 PM, the Medical Director stated medical should always be notified of blood sugars that were out of parameters. The resident goals were trying to maintain blood sugar stability. Changes to monitoring of blood work and changes in insulin would have been important to the resident. During an interview on 12/5/23 at 1:35 PM, nurse practitioner #21 stated that a medical provider should be notified of blood sugars outside of parameters. If the results were off hours telehealth should be called. Nurse practitioner #21 stated that they were aware of Resident #18s elevated blood sugars around 11/14/2023. They had been notified and ordered a urinalysis for symptoms of a urinary tract infection, which could also raise blood sugar levels. They had not been notified of the elevated blood glucose levels on the previous dates. 10NYCRR 415.4(b)

Based on observation, record review and interview during the abbreviated survey (NY00306583), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed. Specifically, when Resident #1 developed maroon, blue, black discoloration on their heels, routine monitoring, treatment interventions, and pressure relief were not implemented when recommended to promote healing and the resident's left heel wound progressed to a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). This resulted in actual harm that was not immediate jeopardy to Resident #1. Findings include: The facility policy Physician-Consultations revised 8/2019 documented a consultant would perform the requested evaluation and provide a consultant's note or report. The attending physician would consider the appropriateness of the consultants' recommendations relative to the resident/patient's current condition, risk factors, existing medication regimen, etc. The attending physician was ultimately responsible for all orders and should remain involved with any aspect of care for which a consultant was involved. As appropriate, the attending physician would approve orders based on consultant recommendations. The facility policy Food and Nutrition assessment dated ,d+[DATE] documented a nutritional assessment, including current nutritional status and risk factors for malnutrition, should be conducted for each resident. The dietitian, with the nursing staff and healthcare practitioners' input, would conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that placed the resident at risk for impaired nutrition. Resident #1 was admitted to the facility with diagnoses including dementia, morbid obesity, and dysphagia (difficulty swallowing). The 7/3/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 with bed mobility, total dependence for transfers, was at risk of pressure ulcers, had no skin impairments, had pressure reducing devices for their chair/bed, and was on a turning and repositioning program. A progress note dated 9/3/22 at 11:00 PM by registered nurse supervisor (RNS) #24 documented they were notified by a licensed practical nurse (LPN) of a circular discoloration to both the resident's heels, with the left heel larger than the right. The left heel was pink/red and dark blue, and the right heel was dark blue/black. The resident's heels were elevated off the bed and the care plan was updated. The impaired skin integrity comprehensive care plan (CCP) initiated 9/4/22 documented on 9/3/22 the resident had discolorations noted to both heels with the left greater than the right. CCP and Kardex (care instructions) interventions included apply protective and preventative skin care and elevate heels off the bed by utilizing a pillow. An Incident Report dated 9/3/22 at 11:00 PM by RNS #24 documented the resident had a skin issue and was found with bruises to both heels. The telemedicine service on-call nurse practitioner (NP #35) was notified on 9/4/22 at 1:00 AM. The incident report documented the family was not notified because the area was a skin discoloration and not an alteration. The resident's heels were elevated. A progress note entered on 9/7/22 at 7:10 PM by licensed practical nurse (LPN) #12 documented they were notified the resident had soft, red areas on both heels. The left heel had a large intact blister, and the right outer heel had a small dark scab. Skin prep (protective barrier) was applied, the nurse practitioner (NP #9) was notified, and a wound care consult would be obtained. A wound evaluation summary by wound care physician #22 entered on 9/7/22 at 8:12 PM documented the resident had a deep tissue injury (DTI, purple or maroon area of intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure) to the right heel that measured 0.5 centimeters (cm) x 0.5 cm. The left heel had a DTI measuring 4.2 cm x 4 cm. The plan included apply skin prep, sponge boots to both feet (a boot that floats the heels from resting on a surface, helping to reduce pressure) and to elevate their legs. A late entry progress note dated 9/7/22 at 3:59 PM (the note did not document when the actual late entry was) by LPN #26 (former wound nurse) documented the resident was seen by the wound care physician for new DTIs to both heels. The left heel was intact (not impaired), and the right heel had a small scab. The resident would dig their heels into the bed to push themselves up. A physical therapy (PT) consult would be ordered, and skin prep would be applied. There was no documented evidence a PT consult or sponge boots were ordered or added to the CCP. On 2/2/23 at 9:37 AM, the Director of Nursing (DON) documented in a correspondence email that physical therapy did not have any consults or notes for the resident around the date of 9/7/22. A 9/9/22 physician order (2 days after wound physician recommendations) documented skin prep to both heels daily and off load heels (elevating the heels to relieve pressure). A wound evaluation summary by wound physician #22 entered on 9/14/22 at 10:54 AM documented the left heel unstageable DTI had a fluid filled blister, had deteriorated, and measured 6 cm x 6 cm. Recommendations included to continue skin prep and switch to a sponge boot. The impaired skin integrity CCP updated 9/15/22 documented the resident had an alteration in skin integrity. Interventions included to evaluate the wound weekly, monitor dressing, report changes to the physician, and refer to the wound specialist as needed. There was no documented evidence the resident had sponge boots added to the plan of care. A nutrition progress note by registered dietitian (RD) #24 dated 9/19/22 at 11:46 AM (16 days after the development of skin impairment), documented they were notified of the resident's impaired skin after reviewing the resident's chart. The resident's estimated needs for skin were 2250 Kcals (calories), 94 grams of protein, and 2250 cubic centimeters (cc) of fluid. Supplements were in place for weight and included super cereal (fortified cereal) for breakfast, and fortified pudding/potato for lunch and dinner. The plan was to continue supplements for wound healing. Nursing progress notes documented: -on 9/24/22 at 3:35 PM by LPN #27 they reported to the RNS the resident's heel wound opened and the original order was to apply skin prep. The RNS stated they would assess the heel. -on 9/25/22 at 6:10 AM by LPN #18 the RNS assessed the open areas on the resident's heel. -on 9/25/22 at 10:40 PM by LPN #29 the resident's left heel was open with a moderate amount of bloody drainage. The area was cleansed with normal saline and a dry sterile dressing (DSD) was applied and covered with Kling (elastic) wrap. -on 9/26/22 at 9:08 AM by LPN #26 the resident's left heel DTI had deroofed (the top of the blister rubbed off) and the right DTI remained closed. The resident was scheduled for the wound physician visit on 9/27/22. There was no documented evidence of an RNS assessment of the resident's heel wounds or a physician order for the applied treatment of normal saline, DSD, and Kling wrap. A physician order dated 9/26/22 documented to cleanse the left heel with normal saline, apply a petroleum wound dressing and cover with a dry dressing every day. A wound evaluation summary entered on 9/27/22 at 7:12 PM by wound physician #22 documented the DTI to the right heel was resolved. The left heel was a Stage 3 (full thickness tissue loss) and measured 4.5 cm x 6 cm x 0.1 cm with 100% necrotic (dead) tissue and moderate exudate (drainage). The plan was to begin collagen powder (sprinkled on a wound to form a protective gel), petroleum wound dressing, covered with an abdominal pad (absorbent dressing) and Kerlix daily. There was no documented evidence wound physician #22's recommended treatment of collagen powder, petroleum wound dressing, covered with an abdominal pad (absorbent dressing) and Kerlix daily were ordered for the left heel wound. On 10/12/22, 10/18/22, and 10/25/22 wound evaluation summaries by wound physician #22 documented the resident's had a Stage 3 pressure wound to the left heel, the wound was improved and continue collagen powder, petroleum wound dressing, abdominal pad, and Kerlix daily. There was no documentation the wound physician's recommendation to add collagen powder was ordered. The 10/2022 Treatment Administration Record (TAR) documented the resident's left heel treatment included cleanse with normal saline, apply petroleum wound dressing and cover with a dry dressing and was administered every day from 10/1/22 through 10/31/22. The 10/19/22 risk for pressure ulcer CCP documented the resident had a history of pressure ulcers. Interventions included sponge boots to both feet to offload heels, inform family of any new area of skin breakdown, and monitor/document/report to physician changes in skin status. The 10/27/22 at 1:19 PM diet technician (DT) #30 progress note documented the resident's weight was down to 203.4 pounds (8 pound loss) though intakes remained excellent at 86%. The resident received double entree portions at meals, double scrambled eggs, and fortified cereal at breakfast, fortified mashed potatoes and fortified pudding at lunch and dinner. The resident consumed 51-75% of supplements/nourishments. The plan was to trial a liquid protein supplement 30 cubic centimeters (cc) twice daily for wound healing support. A 11/4/22 wound evaluation summary by wound physician #22 documented the resident's visit was rescheduled. There was no documentation the resident's wound was assessed by a qualified professional from 10/25/22 to 11/9/22. A wound evaluation summary dated 11/9/22 entered by wound physician #22 (13 days after the last assessment) documented the resident had a Stage 3 pressure wound of the left heel which measured 9 cm x 7 cm x 0.1 cm, was 70% necrotic with moderate serous exudate and had deteriorated. The plan was to continue collagen powder, petroleum wound dressing, abdominal pad and rolled bandage daily. There was no documentation the resident's recommended treatment was ordered. The 11/10/22 physician order documented liquid protein supplement 30 cc twice daily (14 days after recommendations by the diet technician). A wound evaluation summary dated 11/15/22 and entered by wound physician #22 documented the resident had a Stage 4 pressure wound of the left heel measuring 5.4 cm x 6 cm x 0.7 cm. The wound had moderate serous drainage with an odor, was 100% necrotic and had deteriorated. The plan was to change the treatment to a debriding ointment (removes dead tissue), calcium alginate dressing (absorbs wound fluid), covered with an abdominal pad and rolled bandage daily. The 11/22 TAR documented the resident's left heel treatment was to cleanse with normal saline, apply petroleum wound dressing, and cover with a dry dressing and was administered every day from 11/1 through 11/16/22. There was no documentation the 11/15/22 recommended treatment by the wound physician of debriding ointment and calcium alginate was ordered. The 11/15/22 progress note by LPN #23 documented the resident was seen by the wound physician and the left heel had deteriorated. Debridement (removal of dead tissue) was limited by pain. The plan was to debriding ointment/calcium alginate dressing and elevate and offload heels. The 11/17/23 physician order (2 days after recommendation) documented debriding ointment, calcium alginate, abdominal pad and Kerlix daily to heel, and offload heels at all times. From 11/17/23 to 1/17/23, the resident was seen by the wound physician weekly and the Stage 4 pressure wound on the left heel had no documented changes. The 1/18/23 wound evaluation summary by wound physician #31 documented the left heel was a Stage 4 pressure wound and measured 5 cm x 6 cm x 0.3 cm, was 40% necrotic and had no change. The plan was to use gauze-soaked dilute bleach solution, debriding ointment, and cover with abdominal pad and Kerlix. The 1/19/23 physician order documented to cleanse the left heel with normal saline, apply debriding ointment and calcium alginate, cover with abdominal pad and Kerlix. The order did not include gauze-soaked dilute bleach solution as recommended by the wound physician. The 2/1/23 wound evaluation summary by wound physician #31 documented the left heel Stage 4 pressure wound measured 4.6 cm x 3.6 cm x 0.3 cm and had 20% slough (moist, dead tissue) and was improved. The plan was to begin gauze-soaked dilute bleach solution, leptospermum honey (wound treatment containing honey), abdominal pad and Kerlix. The 2/1/23 physician order documented to cleanse the left heel with normal saline, apply honey containing wound treatment followed by calcium alginate, abdominal pad and Kerlix. The order did not include gauze-soaked dilute bleach solution as recommended by the wound physician. The resident was observed: - on 2/14/23 at 8:50 AM, sleeping in a low bed with their covered breakfast tray on the bedside table. The resident had a padded boot on their right foot and the left foot was not visible under a blanket. - on 2/15/23 at 11:09 AM, during a wound evaluation with wound physician #31. The resident's padded booties and the dressing on the left heel were removed. There was a 4.6 cm x 4 cm x 0.2 cm pink/red wound on the left heel with a scant (minimal) amount of slough. Wound physician #31 debrided the wound and the nurse applied the honey containing dressing, calcium alginate and covered the wound with an abdominal pad and Kerlix. During a telephone interview on 2/23/23 at 8:50 AM former wound physician #22 stated when they made recommendations for a wound treatment, the medical providers at the facility would review and approve the treatment, and they expected treatments to be implemented within 24 hours. They stated they had rounded weekly with wound nurses LPNs #23 and #26 and would tell them the recommended treatments. The wound physician would document on the consult form which was uploaded into the electronic medical record. A nutritional assessment should be done within a week after the development of a pressure ulcer and recommended interventions should be implemented as soon as possible. Nutritional interventions were important for wound healing, and the goal was for the resident to have adequate protein stores. If a protein supplement was recommended at the time of the assessment, it should have been ordered then, and waiting 2 weeks was not timely. When the resident's DTI opened on 9/24/22 the skin protectant was no longer appropriate as it could irritate an open wound and they expected medical to be notified for a different treatment to be used. The wound physician stated on 9/27/22 they recommended collagen powder for additional wound healing and was not aware it was not ordered. Wounds should be assessed weekly and if they were not available, they expected an RN to assess the wound. On 11/15/22 the resident's wound had deteriorated, and they ordered the debriding ointment to remove dead tissue and the calcium alginate to absorb drainage and was not aware the treatment had not been ordered until 3 days after the recommendation. During a telephone interview on 2/23/23 at 10:50 AM LPN #23 stated as a wound nurse they assisted the wound physician during wound rounds, took recommendations from the wound physician and addressed them with the facility providers who typically had no issue ordering what the wound physician wanted. A sponge boot required a physician order, and a therapy evaluation was usually needed to obtain the boots. Once ordered the boots would be on the TAR and the resident's care plan. The RN or Unit Manager was responsible to update the care plan. The Unit Manager should notify the RD that a resident had a new skin impairment. An RN should assess wounds when the wound physician was not available. There were RNs available in the facility to assess wounds. The LPN stated when the resident developed DTIs on their heels, they did not recall what interventions were initially in place. LPN #23 did not know why wound physician #22's recommendation of collagen powder was not ordered on 9/27/22. The wound physician would verbally tell them what treatment they wanted during rounds however in the past the verbal order and the wound evaluation summary did not always match so they waited for the completed wound evaluation summary. The wound physician did not always get their summary uploaded into the electronic record timely and that was why the order for debriding ointment and calcium alginate was delayed for 2 days after the wound consult on 11/15/22. During a telephone interview on 2/23/23 at 12:41 PM, RNS #24 stated when a resident had a newly identified pressure ulcer, an RN assessment was done, the physician was contacted, the family was updated, the resident was referred for a wound consult, an accident/incident report was completed, and the care plan was updated. On 9/3/23, they would have notified the on-call provider of the resident's DTI because that was a weekend, and no facility provider was on duty. They did not get an order for the resident's heel because the areas were not open. A wound care referral required a physician's order, and they should have gotten one. During a telephone interview on 2/23/23 at 1:07 PM, former wound nurse LPN #26 stated therapy evaluations and sponge boots required a physician's order and needed to be on the care plan. They were not sure why the therapy evaluation was not completed after they wrote in their note on 9/7/22 that it was ordered. During a telephone interview on 2/27/23 at 8:08 AM, RD #24 stated they needed to know when a resident developed a skin impairment so they could assess the resident's nutritional needs for wound healing. The lead RD went to morning report and if a resident had a new skin impairment, they sent a report out to the nutrition team. RD #24 stated when they made nutritional recommendations, they discussed them with the Unit Manager who was responsible for communicating the recommendations to the physician for an order. RD #24 expected the order to be implemented the same day. RD #24 stated when they wrote their progress note on 9/19/22, they found out about the resident's pressure ulcer after reviewing the record and was not notified prior to that therefore, the assessment was not done timely. RD #24 stated the protein supplement was needed to assist with wound healing. The supplement being ordered 14 days after it was recommended was not timely and could impair wound healing. During a telephone interview on 2/27/23 at 11:50 AM, LPN #12 (former Unit Manager) stated the wound nurses would put the orders in the electronic medical record for the wound physician. They were not aware that skin prep recommended by the wound physician on 9/7/22 did not start for 48 hours after the recommendation and that was not timely. When the resident's DTI opened, they expected staff to report it to the RNS who should assess the wound, call the provider, and document in a progress note. They were not aware there was no documented RN assessment on 9/24/22. Any nurse could send a therapy evaluation in the electronic record and a physician's order was not required and the request was automatically sent to therapy once it was entered in the electronic record. They were not aware the therapy evaluation was not ordered, and it should have been. The former wound nurse LPN #26 was responsible for sending the therapy evaluation. If the wound physician recommended a sponge boot, an order was needed, and it would be on the TAR for a nurse to sign for. The LPN said they were not aware the boot was not ordered. Nutrition staff should have been notified within 24 hours after a resident developed pressure and were typically notified during morning report. The LPN stated they were not aware nutrition was not notified for 16 days after the resident developed a pressure ulcer. The RD was responsible for calling the physician for an order when they recommended a nutritional supplement. The LPN stated, it was not timely when it took 16 days to start the protein supplement for the resident. During a telephone interview with NP #9 on 3/2/23 at 10:30 AM, they stated they expected to be called to review treatment orders from the wound physician and would approve the recommendations. The NP stated they should have been notified for a treatment order for the skin prep and booties when RNS #24 found the resident's heels discolored in September 2022. The NP stated recommendations from the wound physician should be implemented the same day and 2 days for the skin protectant to be implemented was not timely. Nutrition should assess a resident immediately after the development of or a change in a pressure ulcer because nutritional interventions were important for wound healing. If a nutritional intervention was recommended, they expected it to be ordered immediately. When nutrition recommended a protein supplement for the resident it was not timely for the supplement to be ordered 2 weeks later. It was the responsibility of nutrition staff to notify the Unit Manager or the provider to implement their recommendations. When the resident's ulcer opened, they expected an RN to assess the wound at that time. The NP stated that skin protectant was not an appropriate treatment for an open wound as it was very irritating to tissue. The collagen powder should have been added when the wound physician recommended it. The resident did not receive the treatment for 6 weeks after the recommendation and that was not appropriate. When debriding ointment and calcium alginate was recommended on 11/15/22, it was not ordered for 2 days and was not timely. The debriding ointment was needed to remove necrotic dead tissue and calcium alginate was needed for drainage. The NP stated when the wound physician was not available to assess a wound, they expected an RN to assess the resident's wound. 10NYCRR 415.12(c)(2)

Based on observation, interview, and record review during the abbreviated survey (NY00308045) the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed (Resident #92). Specifically, on December 28, 2022, a cognitively impaired resident (Resident #92) with exit-seeking behaviors was able to leave the facility undetected. Staff were not immediately aware the resident was missing. The resident was last seen wearing a coat and hat at approximately 4:00 PM and was identified as missing at approximately 6:00 PM. Law enforcement was notified at approximately 6:45 PM. Later that evening at approximately 8:00 PM a passing motorist called 911 to report an elderly person walking in the middle of a 4 lane road with their walker and cars swerving around them. The resident was located approximately 4 miles from the facility. The resident was returned to the facility by law enforcement at approximately 8:25 PM. The facility did not educate staff or provide additional supervision to the resident when they returned. The facility did not notify New York State Department of Health (NYSDOH) of the incident until January 4, 2023, after the Department questioned the facility about a report of a possible elopement. The facility investigation was not completed timely and did not identify how and when the resident exited the facility. This resulted in no actual harm with the likelihood for more than minimal harm that was Immediate Jeopardy and Substandard Quality of Care for Resident #92. The facility's failure to provide adequate supervision placed 38 residents with elopement detection devices at immediate risk to their health and safety. Findings include: The facility policy Elopement Prevention revised 2/2020 documented the facility maintained a process to assess all residents at risk for elopement and implemented prevention strategies for those identified as elopement risk. Elopement was defined as a cognitively impaired resident's ability to move about inside the facility aimlessly and without an appreciation of personal safety needs and who may enter into a dangerous situation. There was no documented evidence for a policy or procedure for Code Yellow/Missing resident. Resident #92 had diagnoses including epileptic syndrome (seizures), Parkinson's disease (a progressive neurological disease), neurocognitive disorder with Lewy bodies (a type of dementia), and visual and auditory hallucinations. The 12/13/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, had moderately severe depression, wandered 1-3 of 7 days, required limited assistance of one for walking in their room and the corridor, extensive assistance of one for locomotion on and off the unit, was not steady during walking but was able to stabilize without human assistance, used a walker and a wheelchair, and used a wander elopement alarm daily. The impact of wandering section of the MDS was not completed. The resident's comprehensive care plan (CCP) initiated on 4/29/22 documented the resident was at risk for elopement and exhibited wandering behaviors. The resident had past suicidal ideation, hallucinations, and delusions and the resident was not to leave the facility unattended. Interventions included to distract the resident offering diversions, provide a wander alert device, and check the wander alert device placement every shift. There were no subsequent revisions to the care plan. The Elopement risk assessment dated [DATE] completed by registered nurse (RN) #26 documented Resident #92 was fully ambulatory, wandered aimlessly, had made one plus attempts to elope, and had a wander alert device in place. Nursing notes documented: - on 8/11/22 at 1:50 PM by licensed practical nurse (LPN) #27 Resident #92 was exit seeking and asking staff if their spouse was present. The resident was packing their personal items and the Nurse Manager was notified. - on 8/11/22 at 1:50 PM by LPN #27 Resident #92 was to be monitored for wandering, packing belongings, exit seeking, and verbalizing a desire to leave the facility. The Elopement risk assessment dated [DATE] completed by LPN #28 documented Resident #92 propelled self with some assistance, no attempts or history of elopement, was homeless prior to admission, wandered aimlessly, looked for spouse/loved ones, and had major psychiatric or cognitive impairment diagnosis. Nursing progress notes from 8/11/22-10/21/22 did not include documentation Resident #92 voiced a desire to leave, wandered aimlessly, or made attempts to elope. Nursing progress notes documented: - on 10/21/22 at 2:46 PM by RN #29, psychological services staff #37 interviewed Resident #92 and the resident expressed they did not want to live like this, felt they were a burden to the family, and stated they would walk into the street to kill themself. The resident stated they would not be safe if left in their room alone. Staff were to remain with the resident until transport services were made to send the resident to the hospital. - on 10/21/22 At 2:50 PM by LPN #7, Resident #92 expressed wanting to end their life. 1:1 supervision was initiated until the resident was sent to the hospital as the resident had a plan to kill themself. - on 10/22/22 At 12:01 AM by RN #30, the resident returned to the facility from the hospital without new orders and had three follow up appointments. The resident was placed on 1:1 and staff would take turns during that shift. The wander alert device was in place and functioning. - from 10/22/22-10/28/22 the resident remained on 1:1 for suicidal watch. - from 10/28/22-11/5/22 did not document if the resident wandered, made attempts to elope, expressed a desire to leave the facility, or if the resident was monitored for suicide. There was no documented evidence 1:1 monitoring was discontinued after 10/28/22. Resident #92 was admitted to a local hospital from 11/5/22-11/10/22 after an unobserved fall and returned to the facility. The nursing admission progress note dated 11/10/22 at 1:02 PM by LPN #28 documented the resident was at low risk for elopement. There was no documented evidence of an elopement risk assessment for 11/10/22. Nursing progress notes documented: - from 11/10/22-11/16/22 there was no documentation the resident had wandering behavior, eloped or expressed a desire to leave. - on 11/17/22 at 8:47 PM by LPN #31, Resident #92 wandered to Unit A South looking for soda. The wander guard was checked for placement. (The A Unit was located on the other side of the building, across a long hall and down one floor from the resident's unit). There was no documented evidence the resident was assessed after the wandering occurred or if the resident was monitored or if the facility investigated to see how the resident got to Unit A South. Nursing progress notes documented: - on 11/18/22 at 5:09 by LPN #7, Resident #92 was not exit seeking, was ambulating around the unit, occasionally confused but easily redirected. - from 11/19/22-12/1/22 there was no documented evidence the resident expressed a desire to leave the facility or eloped. - on 12/1/22 at 6:20 PM by LPN #7, Resident #92 was angry with placement and having to stay at the facility for so long. The resident was reminded they had upcoming appointments related to their health and that they needed more supervision with their current health issues. The wander alert device was in place. - on 12/2/22 at 1:32 AM by LPN #33, the resident had behaviors, was fully dressed in a coat on at 11:30 PM sitting in the chair next to their bed with a wander alert device on their wrist. The LPN redirected the resident, assisted with changing into their pajamas and into bed. The resident was asleep at that time, and they would continue to monitor. - on 12/2/22 at 2:58 PM by LPN #27, Resident #92 was observed by multiple staff ambulating on the unit without an assistive device. Staff encouraged and redirected the resident to use the device and the resident refused. - from 12/2/22-12/7/22 there was no documented evidence the resident expressed a desire to leave the facility or eloped. - on 12/7/22 at 1:29 PM by LPN #27, Resident #92 was upset with moving to room [ROOM NUMBER]-D (3 South) for safety reasons. - on 12/8/22 at 5:46 PM by LPN #34, Resident #92 walked over to 3 North asking staff how to get out of the building. The nurse checked their wander alert device and directed the resident back to 3 South. Redirection was successful. - on 12/8/22 at 6:32 PM by LPN #31, Resident #92 was exit seeking most of the evening, wanting to get down the elevator to catch a bus. Their wander alert device was in place and medications were given as ordered. The resident was redirected many times. - on 12/9/22 PM by LPN #31, Resident #92 was wandering around the unit without their walker, had difficulty standing and a (certified nursing assistant) CNA put them in a wheelchair (w/c). The resident got themselves up and went to bed. Shortly after, the resident was found wandering in the hall without their walker. The resident had to be redirected many times that evening. The resident was safely in bed and the nurse was at the table right outside the room and would let the oncoming shift know of the behaviors. - on 12/10/22 PM at 5:11 AM by LPN #35, Resident #92 slept very little, was seeking to escape, and was wandering with some confusion. - on 12/15/22 at 12:50 PM by LPN #27, Resident #92 verbalized to staff which door do I use to get out of here. The resident was redirected by staff several times with distraction techniques, i.e., coffee, etc. with negative results. The resident continued to ambulate around the floor with and without their walker. - from 12/16/22-12/26/22 there was no documentation the resident wandered or expressed a desire to leave the facility. - on 12/27/22 at 5:38 PM by LPN #7, the resident required redirection multiple times during the shift. The wander alert device was in place. - on 12/28/22 there was no documented evidence Resident #92 eloped from the facility. The undated facility Full QA (Quality Assurance) Report (Accident/Incident Report) documented an elopement was reported on 12/28/22 at 6:00 PM by Assistant Director of Nursing (ADON) #2. Resident #92 left the facility and was off the premises. The assigned care giver was CNA #3, there were no witnesses, the resident was oriented X 3 (person, place, and time), and had a wander alert device in place. The resident was last observed at 6:00 PM by CNA # 3. The resident was located at their home residence by the resident's family member. There was no wander alert device in place. The elopement details included: - the resident's wander alert device was last checked for functioning and placement at 4:00 PM. - the resident was last seen at 5:00 PM taking a shower. - the resident was noticed missing at 6:00 PM. - the resident was located at 7:30 PM and returned to the facility. No injuries were noted. Actions included the call bell was in reach with instruction, family was called to assist with behaviors, the immediate supervisor was notified, the CCP was updated, outside services were required, a skin assessment was completed, and the resident was assessed head to toe with no injuries, 1:1 supervision was in place and a wander alert device was placed on the resident. The conclusion documented Resident #92 ambulated independently with a walker. On 12/18/2022 (wrong date documented) at approximately 6:00 PM, the resident exited the facility without obtaining a pass or stopping at the front desk. Staff notified the supervisor when the resident was not present for dinner. The facility was searched, and the resident was not present. Police were notified and family was contacted. The resident was located at their former home and was returned to the facility. Upon return the resident was assessed for injury and none noted. Upon interview the resident stated they went home to visit their spouse and child. The resident stated they were unaware of the pass policy and did not know one was needed. The resident was reeducated on the process and a wander alert device was placed. There was no documented evidence the facility ruled out abuse, neglect, or mistreatment, where the resident's previous wander alert device was, how the resident got out of the facility, how long the resident was missing, if the policy was followed, or if this incident was reported to NYSDOH as required. During an interview on 1/5/2023 at 12:40 PM CNA #4 stated Resident #92 was alert and oriented some days and some days they were confused. The resident had a wander alert device on their ankle, and they were not sure which ankle. The resident was independent with ambulation, used a walker, and walked around the entire unit. There was no specific monitoring in place when the resident ambulated and since arriving on the unit 1 1/2 weeks ago. The resident had not made attempts to leave the unit. The resident's wander alert device would prevent the resident from getting on the elevator, if it was removed the resident would be able to leave. During an interview on 1/5/2023 at 12:57 PM CNA #5 stated they worked with Resident #92 while on Unit C-South. When the resident first arrived on the unit, they took care of themself, now their cognition had declined rapidly and there was no specific monitoring in place. The resident would pack their belongings daily stating they were leaving. Redirection worked at times. The resident mostly stayed in their room; staff kept a good eye on them. The CNA would not clarify what a good eye meant. Prior to the elopement the resident did not have a wander alert device, was not supervised with ambulation, and had no specific monitoring. During an interview on 1/5/23 at 1:07 PM CNA #6 stated on the day of the elopement 12/28/22, Resident #92 was ambulating on the unit independently, did not require supervision when ambulating and a wander alert device was located on their left arm. The resident had exit seeking behaviors and redirection usually worked. If redirection did not work, they were to tell the nurse or supervisor. Resident #92 was in the hall and in their room that evening and nothing really caught their attention that indicated the resident wanted to leave. When the resident returned on 12/28/22, 1:1 was provided and continued the next day, but they did not document 1:1 was provided. The CNA stated at about 2:00 PM on 12/29/22 Resident #92 was moved to Unit C-South from Unit 3. During an interview on 1/5/23 at 1:15 PM LPN #7 stated Resident #92 was alert with periods of confusion, anxiety, and paranoia. They were followed by neurology for behaviors, seizures and followed by psychological services when needed. The resident was at risk for elopement and had a wander alert device on their left wrist. The wander guard had been placed on different parts of the resident's body as the resident removed it multiple times. The residents CCP was updated a couple weeks prior to the incident including requiring distance supervision with ambulation as the resident ambulated a lot on the unit. Distant supervision was defined as staff were to keep an eye on the resident from afar. The resident exit seeked mainly on the second shift and staff were to redirect the resident and talk to them. There was no specific monitoring prior to the incident and the wander alert device was checked for placement every shift. After the elopement they were not sure of any new interventions. The day after the incident the resident was moved to another unit to make it more difficult for them to leave the facility. They did not know if the resident had tried to elope before. During an interview on 1/5/23 at 4:05 PM CNA #39 stated each resident should have an order to go outside. Day passes were provided by nurses only. The resident's elopement status was documented on the care card, and they were not aware of any other ways to identify residents at risk for elopement. Resident #92 was alert and ambulated with a walker. They did not know if the resident required supervision when walking. They never saw the resident exit seeking or packing their belongings and they were not assigned to the residents care that day. At a little after 4:00 PM on 12/28/22 they observed Resident #92 standing in the doorway of their room, in their coat and hat. The resident did not say anything, and the CNA stated they did not tell anyone. The CNA stated that was the resident's normal behavior, and the resident often wore a coat. They did not see the resident after that time, and they were not sure if the resident had on a wander alert device. During an interview on 1/5/23 at 4:33 PM ADON #2 for the 3:00 PM-11:00 PM shift stated when a resident was missing, staff were to report it and a Code Yellow (missing person) was paged overhead. The staff would then search every room and the hallways. If the resident was located an all-clear was overhead paged. If the resident was not located the DON and the Administrator would be contacted and they would take over. On 12/28/22 CNA #3 notified ADON #2 around 6:00 PM that Resident #92 was missing. CNA #3 stated they could not find the resident. The resident was last seen going down the hallway to take a shower before dinner, and CNA #3 did not know where or when the resident was last observed. ADON #2 stated they announced a Code Yellow 3 times, then passed out pictures of the resident they printed off the computer. All staff were searching for the resident and when the resident was not found they called the Director of Nursing (DON) at 6:13 PM. The A and I (accident/Incident) report was initiated by ADON #2. ADON #2 stated they provided a statement for the DON and obtained statements from the staff on the unit. The resident often wore a coat and hat when on the unit and they walked the unit using the walker. They did not document the elopement in the nursing notes and only documented the assessment they performed when the resident returned. When the resident returned to the facility, they placed them on 1:1 and applied a new wander alert device. The resident told staff they took off the wander alert device before they left the building. Staff searched for the wander alert device and were unable to locate it. ADON #2 stated they checked the TAR (Treatment Administration Record) on 12/28/22 and saw the resident's wander alert device was checked at 4:00 PM and was in place. During an interview on 1/6/23 at 9:56 AM with Resident #92 they stated they had dementia and it was progressing. They recalled leaving the facility last month at 4:50 PM, no one tried to stop them, and they packed a toothbrush, toothpaste, and a pair of pants. Resident #92 stated being on pass meant they needed permission to leave the facility and they did not ask anyone if they could leave that night, as it was too much work. They had a clear shot out of the building, there were not a lot of people in the lobby and when the receptionist got up, they walked out the front door. No alarms sounded because they left their wander alert device in the bed side drawer as they did not want it to sound. At times they saw things and did not always know where they were. When they were first admitted they thought about hurting themself however did not have any plan now. The resident stated, at times [they] felt alone, like in a fog. The resident stated they did see psychological services however they only came for a few minutes and left stating they would be back. On the night they left the facility they wanted to see the tree, thought about getting home and they did not have any freedom at the facility. They walked all the way to [the street they were located walking in], the sheriff pulled up, and they knew the officer, and the officer took them home. Resident #92 stated they were found walking on the side of the road. The weather was cool outside but not cold, they had their walker and had a coat on. When leaving the facility, they went in the direction of downtown and near a highway, walked around, and saw the tree. The resident stated they bit their wander alert device off and put it in a pocket. When they returned the deputy gave the wander alert device to staff. The resident stated they did not remember much after that. During an interview on 1/18/23 at 10:04 AM CNA #3 stated Resident #92 was previously on the A Unit, moved to 3 South and they were not sure when or why. On 12/28/22 they were assigned to Resident #92. The resident was confused at times. Care needs included the resident was at risk for elopement, they had a wander alert device, staff were to keep an eye on them, and the resident was very fast. The wander alert device was present on their ankle on 12/28/22 at 3:30 PM after the resident finished showering. In the past Resident #92 expressed a desire to leave and would periodically state they wanted to go home. Staff would redirect them and at times that worked. If that did not work, they would notify the Supervisor. The resident did not express wanting to leave the day they eloped. Around 5:30 PM on 12/28/22 they went to check on the resident and could not find then. They looked all over the unit until 5:45 PM, then overhead paged a Code Yellow (missing resident) including the resident's name and room number. The supervisor came to the unit and took over. When the resident returned, they were placed on 1:1 supervision. During an interview on 1/18/23 at 10:34 AM CNA #8 stated they worked as the receptionist at the main entrance a couple of days per week. Training and education included residents going on pass and elopement and there was not much training after that. They were not aware of a picture book for wandering residents at the front desk and did not know how to identify residents who were at risk for elopement unless they had a wander alert device. The front desk was always busy with a lot of people coming and going. They would have to push a button at the desk to let people in and out. They were not familiar with Resident #92, did not know the resident was at risk for elopement, and did not see the resident exit the building. During an interview on 1/18/23 at 10:53 AM Business Office Manager #38 stated during an interview on the day of the elopement, they saw Resident #92, at the elevators, on the first floor, approximately 30 feet from the side door entrance. They were not sure what time that was. The resident asked why people were not able to come and go at the side door. Business Office Manager #38 explained to the resident it was for emergency purposes and if people wanted to leave, they would have to come and go at the front entrance. They were not familiar with Resident #92 and did not know the resident was at risk for elopement. They looked at the resident's wrist and did not see a wander alert device and no alarms were going off. The resident then asked about getting money and they stated that would be done at the front desk. The resident thanked them and headed towards the lobby. During a telephone interview on 1/19/23 at 8:48 AM nurse practitioner (NP) #40 stated Resident #92 had expressed the desire to leave the facility. There had been team meetings held however they were not sure about documentation for those meetings. If any resident expressed a desire to leave, they would expect to be notified, monitoring would be put in place soon as possible after the behaviors or verbalizations, and until a team meeting could be held. The care plan should be updated to reflect the immediate interventions in place. During a telephone interview on 1/19/23 at 9:18 AM attending physician #41 stated during a phone interview Resident #92 had a diagnosis of Lewy body dementia. They were very sick, unreliable and their brain was not good. The resident was at high risk for elopement, and they were aware the resident expressed a desire to leave the facility. If any resident expressed a desire to leave the facility, they would expect the staff to heighten their awareness which may include 1:1 or 15-minute checks and should be updated in the resident's care plan. They were aware the resident eloped from the facility on 12/28/22 and stated the resident had no judgement and their cognition was not good. The resident should have been watched more closely if they expressed they wanted to leave. During a telephone interview on 1/19/23 at 10:44 AM the DON stated Resident #92 did not have a diagnosis of dementia in their medical chart. Staff had reported to them the resident expressed on occasion they wanted to go home and be with their spouse. Staff had not reported to them the resident had exit seeking behaviors or expressed a desire to leave the facility. They stated to their knowledge the resident did not attempt to elope before 12/28/22. They were not aware the resident left Unit 3 South and went to the A building to get soda. They stated they would have expected an understanding as to how the resident got off the unit and some form of documentation. They did not know why the elopement was not documented in the nursing notes. ADON #2 completed the elopement incident /accident report, and the DON completed the conclusion on 1/4/23. The DON stated they concluded Resident #92 exited the facility with the intention to go to their home. The resident was not wearing a wander alert device, so the alarms did not sound, and staff let the resident exit the building. After being located by police at their home address, the resident was brought back to the facility. The resident was assessed and had no injuries. The DON stated they determined after looking at the incident reporting manual, due to the resident being alert and oriented without impaired cognition, this was not an elopement and not a DOH reportable incident. During a telephone interview on 1/18/23 at 12:28 PM the Administrator stated a reportable incidents were incidents that met the standards of reportable guidelines. Reportable incidents included choking, falls with injury, CP violations and abuse. In certain circumstances elopements were reportable and they would have to refer to the reporting manual for guidance. Elopement was defined as someone without capacity that could not make safe decisions and had no regards for their safety wandering out of the facility. Resident #92 had a BIMS (Brief Interview for Mental Status) of 12 (moderately impaired cognition), the resident was able to make decisions and that was considered mild impairment. The Administrator stated they would discuss incidents during QA (Quality Assurance) meetings and at times during morning meetings. In this case, the DON had direct oversight of the investigation. The Administrator stated at first, they did not consider the Resident #92's incident an elopement but after reviewing the police report it could be considered an elopement. An incident report should be completed within 5 days, and if considered abuse, reported within 2 hours. All other incidents were to be reported within 24 hours. Resident #92's investigation should have been completed within 5 days. They had a facility policy elopement prior to 1/5/2023 when DOH entered the building and they were not sure if the policy had been updated. If a resident packed belonging, verbalized wanting to leave or had exit seeking behaviors the wander alert device would be considered the monitoring system. ------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility Administrator was notified on 1/5/23 at 7:57 PM. Immediate Jeopardy was removed on 1/10/23 at 12:28 PM, prior to survey exit based on the following actions taken: -100% on-duty staff education regarding elopement prevention & supervision and additional education for nursing staff, additional staff computerized training prior to starts of shift; -Completion of elopement and wandering assessments throughout the facility. -Revisions to care plans. -Implementation of wander alert device checks and hourly rounding for residents at risk for wandering and other appropriate measures as needed (increased supervision, 1:1). -Resident room changes were made to help mitigate elevator risk and distance from points of exit. -Elopement risk photo collage was updated and included on units. -New (more rugged) bracelet bands for wander alert transmitters; and -Revisions to elopement policy. 10 NYCRR 415.12(h)(1)

Based on record review and interview during the abbreviated surveys (NY00292089 and NY00297468) the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents reviewed. Specifically, Resident #5 did not receive anti-rejection medication (used after organ transplant) as ordered for 4 days and the physician was not notified. Additionally, Resident #5 did not receive bi-weekly medication for anemia (Aranesp, aids in red blood cell production to reduce or avoid the need for transfusions), the physician was not notified, and the missed Aranesp dose was not rescheduled, the resident was hospitalized due to anemia and required a blood transfusion. Resident #7 was to receive a monthly intravenous (IV) medication that was not provided during their stay at the facility, there was no plan to ensure the resident received it during their stay, and there was no plan for the resident to receive it following their discharge. Findings include: This resulted in actual harm to Resident #5 who developed critical hemoglobin (Hgb) and hematocrit (Hct) lab values and required a transfusion. The facility policy Medication Administration Review revised 8/2019 documented: - Licensed nurses were to ensure that prior to the end of their shift, all medications/treatments administered/held/refused, etc. were properly documented on the Medication Administration Record (MAR). - Failure to do so was considered an omission in the medical record. - The facility would review completion reports during daily clinical meetings for review of potential omissions of documentation. Nursing management would follow up with the nurse within 24 hours to correct documentation if applicable. The facility policy Medication Not Available Guideline revised 1/14/22 documented the licensed nurse on duty was responsible to: - Notify the pharmacy of medication unavailability; - Notify the physician of medication unavailability; obtain the next course of action such as changing next dose time(s), changing medication to what is readily available in-house, pending pharmacy delivery; - If the medication was unavailable from the pharmacy, the facility should obtain alternate physician/prescriber orders; - If the licensed nurse was unable to obtain a response from the attending physician/prescriber in a timely manner, the nurse should notify the nursing supervisor; - The licensed nurse should document missed doses on the Electronic Medical Record (EMR) and on the 24-hour report; - Documentation should include explanation of missed dose including actions taken, such as notification of physician to include further orders, adjustment of medication time changes, proposed medication delivery time/day by the pharmacist, third-Party authorization/delivery, assessment/evaluation of the resident related to missed medication; other action to address the missed medication; and - If the medication was not received the nurse should notify the Director of Nursing (DON)/designee and follow up with the physician and pharmacy 1) Resident #5 had diagnoses including iron deficiency anemia (insufficient red blood cells to carry oxygen), end stage renal disease, and post kidney transplant status. The 6/13/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of one to two for activities of daily living (ADLs), and did not receive any intravenous (IV) medications in the previous 14 days. The 6/9/22 hospital discharge summary documented medication orders including: Envarsus extended release (XR) (tacrolimus, anti-rejection medication for kidney transplant), 1 milligram (mg), take 1 tablet every morning beginning 6/10/22 and continue Aranesp injections. The 6/9/22 physician orders documented: - Aranesp solution 100 micrograms (mcg)/0.5 milligrams (ml), inject 0.5 ml subcutaneously (under the skin) in the morning every 14 days for anemia treatment, start date 6/10/22; - Envarsus XR tablet, 1 mg in the morning, start date 6/10/22. The 6/9/22 Admission/Readmission Evaluation, completed by registered nurse (RN) #72 documented a drug regime review was completed and no potentially clinically significant medication issues were identified since the admission. The 6/9/22 comprehensive care plan (CCP) initiated 6/17/22 documented the resident had anemia/history of anemia. Interventions included monitor and report to the physician signs of anemia and administer medications as ordered. The 6/2022 medication administration record (MAR) documented: - Envarsus XR tablet, 1 mg in the morning, was not administered 6/10-6/13/22 (4 days). The reason code was other/see nurse notes. - Aranesp solution 100 mcg/0.5 ml, inject 0.5 ml subcutaneously in the morning every 14 days for anemia treatment, due 6/10/22 and 6/24/22. The medication was not administered 6/10/22, with the reason code other/see nurse notes. The resident was hospitalized on [DATE] and did not receive the scheduled dose on that day. There were no documented corresponding nursing notes related to the medications that were not administered, no documented evidence the Aranesp administration was rescheduled, and there was no documented evidence the medical provider was contacted when the medications were not administered as ordered. The 6/13/22 at 9:01 AM physician #73's progress note documented the resident was post-renal transplant and the physician had concerns that all the resident's medications may not be in, was not certain how to clarify in the EMR and was to ask the pharmacist consultant to review post-haste (immediately). There was no further documentation in the resident's medical record related to the status of the Aranesp, missed doses, or physician notification. The 6/23/22 laboratory report documented critical results including: - hemoglobin (HGB, protein in blood that carries oxygen) was 6.0 grams per deciliter (g/dL, normal range 12.0-16.0 g/dL); and - hematocrit (HCT, percentage of red blood cells) was 19.2% (reference/normal range was 36-47%). The 6/23/22 at 2:40 PM nursing progress note documented lab results were reviewed with nurse practitioner (NP) #4 with new orders. The 6/23/22 physician order documented to send the resident to the hospital for symptomatic anemia. The 6/29/22 hospital discharge summary documented the resident was admitted on [DATE] and received a blood transfusion. The discharge diagnoses included anemia and cystitis (inflammation of the bladder). The discharge orders included to continue the Aranesp injection. The 6/29/22 physician orders documented: - Aranesp solution 100 mcg/0.5 ml, inject 0.5 ml subcutaneously in the morning every 14 days for anemia treatment, start date 6/30/22. The 6/2022 and 7/2022 MARs documented: - Aranesp solution 100 mcg/0.5 ml, inject 0.5 ml subcutaneously in the morning every 14 days for anemia treatment, due 6/30/22, and was not administered. The reason code was other/see nurse notes. - The next scheduled dose was 7/14/22 (the resident was discharged on [DATE]). There were no documented corresponding nursing notes related to the medication that was not administered on 6/30/22, no documented evidence the Aranesp dose was rescheduled, and there was no documented evidence the medical provider was contacted. The 7/4/22 at 10:31 AM physician #73's progress note documented the resident returned to the facility after hospitalization for anemia from renal failure for which they received PRBCs (packed red blood cells). The physician noted concern that all the resident's medications may not be in, was not certain how to clarify in the EMR and was to ask the pharmacist consultant to review post-haste. During a telephone interview with pharmacist consultant #75 on 7/28/22 at 2:21 PM, they stated the pharmacy called the facility, communicated through the pharmacy portal, and emailed stating blood work was needed for the Aranesp, and they never received a response. Upon review of the resident's medication record, the pharmacist noted that the Aranesp was not given on the day it was due (6/10/22), and was not rescheduled, as it should have been due to it being a bi-weekly administration. The pharmacist stated Aranesp was for red blood cell production and failure to receive the medication as scheduled could result in loss of red blood cells. On 6/15/22, the pharmacist consultant sent an email documenting potentially clinically significant concerns to the facility and included the Administrator, Medical Director, Director of Nursing (DON), Assistant DONs (ADONs) #8 and 77, and physician #73 stating the resident had not received their Aranesp that was due 6/10/22, it had not been rescheduled and they had not received Envarsus 6/9-6/13/22. Their email included a list of other residents with similar concerns regarding missed/late medications. During a telephone interview with physician #73 on 8/18/22 at 2:00 PM, they stated when they discovered the resident had not received their Envarsus for 4 days, they became concerned as it was needed to prevent organ rejection due to the resident's kidney transplant. The physician expected staff to call them or the on-call provider if a medication was not administered as ordered and they were not notified. The physician stated the resident should not have been discharged from the hospital prior to a weekend with a medication such as Aranesp. They recalled asking for clarification about the medication and could not recall the outcome. When a medication was scheduled bi-weekly and not administered on the day it was due, it needed to be rescheduled rather than waiting for the next scheduled dose. The physician was not certain if the missed dose of Aranesp on 6/10/22 was directly related to the resident's anemia and need for a blood transfusion on 6/23/22. The 8/19/22 email communication from the facility's pharmacy documented: - The order for Envarsus was received electronically on 6/9/22 at 5:59 PM. - On 6/9/22 at 12:52 AM, a pharmacist's note stated the medication was out of stock, the item was ordered, and they spoke to a nurse at the facility. - On 6/14/22, the order was received in stock at the pharmacy and processed for dispensing. - On 6/15/22 at 12:25 AM, the Envarsus was delivered and signed for at the facility. The 8/22/22 email communication from the facility's pharmacy documented: - The order for Aranesp was received on 6/9/22, but valid labs were not received. Multiple attempts were made to inform the facility. - The pharmacy required hemoglobin and hematocrit values drawn within 28 days of any Aranesp dispense. There was a Black Box Warning associated with all Erythropoiesis-Stimulating Agents (ESAs), including Aranesp, which stated there was an increased risk of death, serious adverse cardiovascular reactions, and stroke when the hemoglobin value exceeds a certain level. - A message was sent via a secured site used for communication between the facility and the pharmacy to clarify on 6/10/22 around 12:37 AM. - The pharmacy followed-up via phone on 6/10/22 around 8:44 AM, and 6/11/22 around 3:23 PM. They were unable to successfully reach anyone. - The request for Aranesp medication was made again via the online messaging system on 6/30/22. Lab values were retrieved, and the medication was processed. - High-cost authorization was required and was received on 07/1/22. - The medication was out of stock on 7/01/22 and was processed and delivered on 07/02/22. During a telephone interview on 8/30/22 at 1:03 PM, licensed practical nurse (LPN) #81 stated there were multiple issues with medications not being available for residents. Resident #5 had medications that were not available when they were admitted . The LPN recalled asking a supervisor if the medications were reviewed prior to admission due to them being high-cost medications that were typically not supported by the facility. This was an ongoing issue at the facility and all the LPN could do was notify the supervisor, as making direct calls to medical providers was discouraged and had to be routed through supervisors. The LPN reported to the supervisor when the Envarsus and Aranesp were not available and was told they were high-cost medications, and they were taking care of it. During a telephone interview with NP #4 on 8/30/22 at 1:21 PM, they stated they were not made aware that Envarsus was not provided for 4 days and that the Aranesp was not administered. When the Aranesp was not administered on 6/10/22, the NP or another medical provider should have been notified to reschedule the medication prior to the next scheduled dose (14 days later). When the resident was hospitalized on [DATE], it could have been related to the missed Aranesp dose, as the medication stimulated red blood cell production, the resident was anemic and required a blood transfusion. When the resident returned on 6/29/22, the Aranesp was due to be administered on 6/30/22 and was not available. When it became available it should have been rescheduled as the next dose was not due until 7/14/22. The RN Managers and DON were responsible for responding to pharmacy inquires and to notify the medical provider of any missed or unavailable medications. During a telephone interview with the Medical Director on 8/30/22 at 2:08 PM, they stated Envarsus was an essential medication, and a medical provider should have been notified when it was not available for administration. When the Aranesp was not administered on 6/10/22, it should have been rescheduled as soon as possible, prior to the next scheduled dose. The RN Manager was responsible to notify the physician to obtain a new dosage schedule. The Medical Director was not made aware of the pharmacy requests for the blood tests. The admitting physician would make the determination of ordering blood work. During a telephone interview with LPN Manager #82 on 8/31/22 at 2:00 PM, they stated when the resident was first admitted , they were on leave and was unaware of any issues related to the resident's medication availability. When the LPN Manager returned to work, they were not made aware the Aranesp was not administered or received in the facility. Following the resident's hospitalization and return to the facility, the LPN Manager was not made aware the Aranesp was not administered as ordered on 6/30/22. When a medication dose was missed, it was a medication error and the medical provider needed to be notified. The electronic medical record (EMR) would show an alert on the resident's dashboard for 24 hours, which should signal the nurse to notify a supervisor about the medication. When the medication was received on 7/2/22, there was no order to provide it at that time, as the dose was missed on 6/30/22 and not due again until 7/14/22. LPNs were expected to notify a supervisor and not the physician unless there was an issue off-hours. During a telephone interview with the Assitant Director of Nursing (ADON) #77 on 9/1/22 at 9:56 AM, they stated they did not oversee Resident #5's building, ADON #8 was assigned to the floors where Resident #5 resided. When a medication was missed, the nurse was to notify the supervisor, document in the progress notes, and notify the provider. The ADON received the email communications from the pharmacy consultant and stated the ADON assigned to the resident's unit (ADON #8) was responsible to follow up on the issues identified in the emails. ADON #77 recalled the 6/15/22 email from the pharmacy consultant and stated they educated nursing staff on using the online communication system with the pharmacy, documenting missed medications, what they did about it, and provider notification. The ADON stated the lack of documentation related to missed medications was an ongoing issue that she often educated nursing staff about. During a telephone interview with ADON #8 on 9/1/22 at 10:42 AM they stated they were not made aware of any issues related to Resident #5's medications. They were responsible for coverage of the resident's unit and may have overlooked the emails. The proper procedure would be via the pharmacist consultants review reports versus a standard email, as they received hundreds of emails and they may not be able to address them timely. If a medication was not sent from the pharmacy, it would be up to the nurse on the medication cart to address the missing medication, notify the supervisor or nurse manager for further instruction and document accordingly. The nurse manager was expected to notify the medical provider and document in progress notes what was done or to be done. A bi-weekly medication that was not administered needed to be rescheduled by the medical provider. During a telephone interview with the DON on 9/1/22 at 11:06 AM they stated the protocol for a missed or unavailable medication was for the nurse to notify the nurse manager, supervisor or medical provider and document in the medical record. Whenever the pharmacy needed clarification or laboratory results for a medication, they would call the supervisor's phone or send a message through the secured online communication system. Whoever received the information was responsible for follow-up. The DON was not made aware of any issues regarding Resident #5's Aranesp and stated it should have been reviewed with the medical provider to be rescheduled if the doses were missed. When the Envarsus was not available for administration, the nurse should have notified the supervisor or medical provider. Missed medication doses were medication errors due to omission without orders to hold or reschedule the medication. 2) Resident #7 had diagnoses including dermatomyositis (inflammatory disease with muscle weakness and skin rash) with myopathy (muscle weakness), and myocardial infarction (heart attack). The 2/18/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of 2 for bed mobility, limited assistance of 2 for dressing, toileting, and hygiene, was totally dependent on staff for eating, and did not receive any intravenous (IV) medications in the previous 14 days. The 2/11/22 hospital discharge summary documented IVIG (intravenous immunoglobulin, used were to reduce the effects of some inflammatory conditions that involve the immune system), 130 grams (gm), split as 65 gm daily over 2 days. The last doses were on 2/2/22 and 2/3/22. The 2/11/22 at 3:53 PM nursing progress note entered by registered nurse (RN) #15 documented the resident last had IVIG 130 gm delivered over 2 days in 65 gm doses on 2/2/22 and 2/3/22. The resident received the infusion monthly. They called the pharmacy and were informed IVIG could not be provided to them due to stability issues. The RN called and spoke to the rheumatology office where the resident had an appointment on 3/2/22 and asked if the resident was having the IVIG infusion at this appointment. The resident was not to have the infusion at the appointment and the nurse needed to follow up Monday 2/14/22 on where the infusion can be done. The 2/12/22 History and Physical completed by physician #76 documented the resident had dermatomyositis and IVIG transfusions monthly, 2 g/kg equals 130 gm divided over 2 days, last dosing 1/1/22 and 1/2/22, then 2/2/22 and 2/3/22. The plan included rheumatology consult, follow up for guidance regarding management of dermatomyositis and IVIG infusions. There were no documented nursing or medical progress notes related to follow-up on the IVIG infusions. The 2/28/22 social work progress noted entered by social worker (SW) #56 documented a care plan meeting was held 2/24/22 and discharge was discussed with the resident and their family members via phone. The anticipated date of discharge was 3/8/22. The resident needed an IVIG flush done very soon. The 3/3/22 rheumatologist After Visit Summary documented medication changes that were signed done above each, and needs monthly IVIG infusions 1 gm/kg for 2 days each month with no corresponding notation. The document was initialed by nurse practitioner (NP) #4 on 3/4/22. The next appointment for the rheumatologist was 6/15/22. The 3/3/22 at 9:54 AM nursing progress note entered by RN #74 documented the resident returned from a rheumatology appointment, schedule monthly IVIG 2 doses. The 3/7/22 NP #4 progress note documented all prescriptions e-scribed to the resident's home pharmacy. The 3/7/22 Discharge Summary and discharge orders did not contain any documented evidence of instructions for the IVIG infusion or follow up with the rheumatologist. RN #74 was not able to be reached for interview and no longer worked at the facility. During a telephone interview with RN #15 on 8/2/22 at 11:20 AM, they stated they briefly covered Resident #7's unit as RN Manager and could not recall the outcome for the IVIG transfusion. They stated if there was a question as to arranging the infusion, they would address it with the DON or medical provider, and it should have been documented in the nursing progress notes. During a telephone interview with the Resident's spouse on 8/18/22 at 11:20 AM, they stated the resident was to receive their IVIG treatment on 3/2/22 and 3/3/22 and the facility did not provide it. SW #56 told them the facility would not provide it with no further explanation. When the resident was discharged on [DATE], there was no plan for them to receive the IVIG infusion. The resident was hospitalized on [DATE] after going home and received their infusion at the hospital. SW #56 was not able to be reached for interview and no longer worked at the facility. The 8/19/22 email communication from the facility's pharmacy documented they were unable to locate any orders for IVIG for Resident #7. The 8/22/22 follow-up email communication from the facility's pharmacy documented they were unable to retrieve information related to the phone call from the facility to the pharmacy on 2/11/22 in which the facility was advised the medication could not be provided due to stability. The pharmacy representative stated they were able to provide IVIG on a case-by-case basis depending on the details of the order and available resources at the facility to provide proper administration and monitoring. During a telephone interview with NP #4 on 8/30/22 at 1:35 PM, they stated they did not do IVIG infusions at the facility and it should have been set up for the resident to receive the infusion at their rheumatologist's office or the hospital. The Nurse Manager should have followed up upon finding out it would not be done at the rheumatology appointment. If there was a plan for the resident to receive the infusion following discharge, it should have been addressed in the discharge summary. During a telephone interview with the Medical Director on 8/30/22 at 2:21 PM, they stated the RN Manager should have followed up with the medical provider to ensure the resident was scheduled to receive the infusion. When the resident returned from the rheumatology appointment, NP #4 signed off on the consultation and the Medical Director usually countersigned, and this may not have been done. The facility should have followed up or scheduled the IVIG infusion prior to the resident's discharge. During a telephone interview with the DON on 9/1/22 at 11:06 AM they stated they were not familiar with any issues related to Resident #7's IVIG infusions. They would not be able to provide the infusions at the facility and other arrangements should have been made. When the nurses were made aware it was not given at the rheumatologist's office, the DON expected they would have followed up with the medical provider for further instruction. If the resident was discharged before the plan was made, it should have been included in their discharge plan via follow up appointments to ensure the resident received the needed treatment. 10NYCRR 415.12(m)(2)

Based on record review and interview during the abbreviated survey (NY 477) conducted on [DATE], the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility in a form and manner that the resident can understand for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1, who lacked medical decision-making capacity and was non-English speaking, was discharged without a representative present, and their medications were not reviewed or verified at the time of discharge. Resident #1 was discharged with a supply of medications that were ordered for Resident #2. Resident #1 ingested those medications for 7 days after discharge resulting in medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Findings include: The facility Discharge Plan policy, revised ,d+[DATE], documents: - a post-discharge plan which includes a plan for medications shall be provided to the resident, and/or their representative at the time of discharge. - The post-discharge plan will include current medications, including narcotics, analgesics with the type, dose, and prescribed to the resident discharged ; a description of how the resident and family needs to prepare for the discharge. - Prior to discharge, a reconciliation of all discharge medications is conducted with pre-admission medications, including prescribed and over the counter medications. - Social services or designee reviews the plan with the resident and family before the discharge is to take place. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment. Resident #1's Medical Orders for Life-Sustaining Treatment (MOLST) signed by the physician on [DATE], documented the resident lacked decision-making capacity and a family member was identified as their Public Health Law (PHL) surrogate (immediate family member identified when there was no healthcare proxy). Social worker (SW) #2's [DATE] progress note documented they spoke to the resident's PHL surrogate to review discharge plans for [DATE] and the PHL surrogate and another relative planned to pick up the resident on [DATE] at 2:00 PM. Registered nurse (RN) #6's progress note on [DATE] documented RN #6 spoke to the resident's PHL surrogate about the resident's insulin. The PHL surrogate stated they were comfortable administering insulin and was able to verbally review the steps to doing finger sticks (checking blood sugar) and administering insulin with a pen (injection). There was no documented evidence the facility communicated discharge medication orders (other than insulin) or discharge instructions to Resident #1's PHL surrogate. The [DATE] pharmacy delivery manifest (30 day medication supply to be sent home with the resident), signed as received by RN supervisor (RNS) #9, documented Resident #1's medication order contained a one month supply of the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Resident #1's Medication Discharge Form dated [DATE] documented the following discharge instructions which were incorrect as they were not consistent with the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] monotritate ER, 30 milligrams (mg) tablet, documented to take as needed on the Discharge Form when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)] 2.5 mg tablet, 1 tablet twice a day with the next dose due on [DATE]. This was incorrect as it was ordered for twice a day and the ,d+[DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . - [MEDICATION(S)], 40 mg tablet, was crossed off on the Discharge Plan when there was no documentation in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The form had initials (illegible) above the area for the resident's name. Resident #1's [DATE] Discharge Plan Instructions documented: - the medication list was attached, the resident's family member was able to verbalize doing fingersticks and administering insulin, and a copy was given to the resident. - The questions whether skilled education was given and if the resident/responsible party were able to return demonstration was not answered. - The above sections of the Discharge Plan were documented as completed by RN Manager #1. - SW #2 documented they completed other sections of the form related to the discharge plan including who the resident was going home with and services needed. - The resident's initials were on the signature line. The [DATE] pharmacy Discharge Acknowledgement of Receipt of Medications form documented: - Resident #1's name, date of birth, and phone number were written on the form and the area for the resident's initials to provide consent and agreement for the pharmacy's services was left blank. - The resident's PHL surrogate was named as the responsible party. - SW #2's name was printed after Signature of Discharging Resident/Responsible Party. - Name and Signature of Facility Staff Member was left blank. The [DATE] nurse practitioner's (NP) Discharge summary documented: - The resident was initially admitted for post-acute care secondary to coronary artery disease after complications with stents, [CONDITION(S)] (infection that spread to the blood) and [CONDITION(S)]. The resident required temporary hemodialysis. - The resident was medically stable to be discharged to their relative's home in another state. - The discharge medications were well documented in the permanent medical record and a 30-day supply of medications given to the resident. On [DATE], the resident's primary care physician (PCP #8) in the community reported the following to the New York State Department of health (NYS DOH) via email: - Resident #1 was discharged from the nursing facility and moved out of state where PCP #8 took over their care. - Resident #1 came to PCP #8's office on [DATE] for an appointment and brought the discharge paperwork and medications received from the nursing facility. The discharge paperwork included some of another resident's discharge paperwork (Resident #2) and several sheets of Resident #1's discharge paperwork were missing. - PCP #8 reviewed the pill packs Resident #1 received from the facility and noticed there were pills labeled for Resident #2. - Resident #1 received medications that were not ordered for them including [MEDICATION(S)] (anticonvulstant), [MEDICATION(S)] ([CONDITION(S)] medication), and [MEDICATION(S)] (medication for muscle spasms). PCP #8 noted Resident #1 had [CONDITION(S)] and was elderly and some of the medications provided could worsen kidney function and are generally unsafe in the elderly. PCP #8 noted [MEDICATION(S)] in someone with normal [CONDITION(S)] function can cause [CONDITION(S)] (over-active [CONDITION(S)] function) which can be deadly. - PCP #8 checked the resident's blood work and noted the resident was in renal (kidney) failure possibly related to these medications and had [CONDITION(S)] (high potassium). The resident was referred urgently to the emergency room (ER) where Resident #1 went into [CONDITION(S)] (sudden stopping of the heart), possibly due to elevated potassium levels. During a telephone interview with PCP #8 on [DATE] at 11:18 AM, PCP #8 stated when Resident #1 came to their office on [DATE], their PHL surrogate brought the medications the resident was sent home with from the nursing facility. PCP #8 stated Resident #1's medications were attached to medications for Resident #2. The PHL surrogate stated they gave Resident #1 medications from both of the pill packets (Residents #1 and #2's medications). PCP #8 stated, Resident #1 had taken Resident #2's potassium which was most concerning to PCP #8 as Resident #1 had kidney disease. PCP #8 stated individuals with kidney disease should avoid potassium because the kidneys cannot remove excess potassium. PCP #8 stated the resident's PHL surrogate told them Resident #1 took Resident #2's potassium for 7 days. The resident had bloodwork completed at the office and had a potassium, level of 7.4 milimoles per liter (mmol/L, normal = 3.,d+[DATE].2 mmol/L), which indicated a very high risk of [CONDITION(S)]. PCP #8 instructed the resident's PHL surrogate to take the resident to the emergency room (ER) immediately. The resident's potassium had since come down and they were stable, which led the physician to believe the [CONDITION(S)] was related to taking supplemental potassium from [DATE] to [DATE]. PCP #8 stated other factors for the resident's elevated potassium level were ruled out including the need for [CONDITION(S)] and the resident no longer needed [CONDITION(S)]. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the medical record, Resident #2 was scheduled for discharge on the same date as Resident #1 ([DATE]) and the discharge was delayed related to a fall and the need for additional therapy. The [DATE] hospital ER record documented: - the resident presented with weakness and [CONDITION(S)] (slow heart rate). - At an appointment that morning, it was discovered the resident had been taking medications prescribed to someone else, labs were drawn, and their potassium was found to be 6.7 mmol/L (normal=3.,d+[DATE].0 mmol/L) and creatinine (measure of kidney function) was 4.09 mg/deciliter (dL, normal= 0.,d+[DATE].2 mg/dL). - In the ER, the resident was put on a cardiac monitor and their heart rate was noted to be in the 20's (normal range = ,d+[DATE]). - During the examination, the resident seized and became unresponsive, went into [CONDITION(S)], was given one round of CPR (cardiopulmonary resuscitation), intubated (breathing tube inserted), and renal (kidney doctor) was consulted. - Hospital laboratory results documented the resident's potassium level was 7.4 mmol/L(normal=3.,d+[DATE] mmol/L) on [DATE] at 2:48 AM. - The resident presented with [CONDITION(S)] and was now in the MICU (medical intensive care unit) after suffering bradycardic (low heart rate) arrest likely from [CONDITION(S)]. During an interview with SW #2 on [DATE] at 11:23 AM, they stated their role in the discharge process included setting up the discharge meeting, reviewing home needs, and ensuring services were in place. The facility had a program with the pharmacy to provide residents a 30-day supply of medications at the time of discharge to home. SW #2 was responsible to send residents' orders to the pharmacy within 1 to 2 days prior to discharge so the medications were available residents when they left the facility. SW #2 began the discharge paperwork and other departments (therapy, nursing, etc.) completed their sections of the discharge. Once the discharge paperwork was completed, SW #2 printed the discharge instructions and the nurse reviewed the paperwork with the resident or their representative upon discharge. SW #2 did not review discharge medications, that was done by a nurse at the time of discharge. Resident #1 was limited in speaking English, understood some communication, and the facility utilized the language line or had the family translate when needed. SW #2 stated it would not be appropriate for a staff member to review the discharge paperwork or medication instructions with Resident #1 due to their language barrier. RN Manager #1 stated in an interview on [DATE] at 12:18 PM: - on the day of discharge, RN Manager #1 obtained the 30-day supply of medications from the medication room to be sent home with the resident. - At the time of discharge, RN Manager #1 checked the Medication Discharge form against the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - RN Manager #1 stated they normally reviewed the Medication Discharge form with the resident and placed the form and discharge instructions in the pharmacy bag with the 30 day supply of medications. If the resident was unable to understand the discharge instructions, the family would be called to review the discharge instructions and this would be documented in the resident's record. Family members were not permitted to the units for discharge related to limiting visitors to the unit due to COVID-19 concerns so RN Manager #1 would review the instructions with the resident, and another staff member brought the resident to the lobby for pick-up. - Resident #1 did not speak English and prior to discharge, RN Manager #1 stated they spoke to the resident's PHL surrogate about the discharge. - Other family members picked the resident up on [DATE] and RN Manager #1 did not see the family or speak to them. - RN Manager #1 stated they reviewed the discharge paperwork with Resident #1 and did not open the bag of medications (30 day supply of medications) or review them as the resident could not speak English. - RN Manager #1 stated they did not look in the bag of medications to ensure they were the correct medications as they expected the nurse who received the order from the pharmacy to verify they were correct. - When Resident #1 was discharged on [DATE], RN Manager #1 provided them with their medications, did not see the family, did not look in the bag of medications, and a certified nurse aide (CNA) brought the resident to the lobby. During an interview on [DATE] at 3:20 PM, the Director of Nursing (DON) stated when the 30 day medication supply was received form pharmacy, the receiving nurse was to review the medications and sign the pharmacy form. After hours, this nurse was the RN Supervisor (RNS). During a telephone interview with Resident #1's PHL surrogate on [DATE] at 12:59 PM, they stated: - prior to the resident's discharge, they spoke to a nurse about insulin and checking blood sugar, and no one called them about other medications or discharge instructions. - They stated they live in another state so other family members picked the resident up from the facility. They stated no one from the facility spoke to the other family members at the time of discharge about instructions. - The resident arrived to PHL surrogate's home with 2 pharmacy bags, one with their name on it and one with Resident #2's name, although they did not notice Resident #2's name at the time. Since the pill packets were stapled together, they did not realize the pills were for Resident #2. Both Residents #1 and #2's medications were given to Resident #1 from [DATE] to [DATE]. - One bag also contained discharge paperwork for Resident #2 and a lab report for another unidentified resident. - On [DATE], the resident had an appointment with PCP #8 and the PHL surrogate brought all of the medications to the appointment and at the appointment, PCP #8 noticed some of the medications Resident #1 had been taking were for Resident #2. - Blood tests were completed and the resident had a high potassium level. They went to the ER and shortly after checking into the ER, the resident went into [CONDITION(S)] and had a heart attack. The resident's condition following the heart attack declined, as they now had difficulty swallowing, declined mental status, and could not walk as they could before. They stated they thought the resident would now require another stay in a rehabilitation center before they were able to go home. On [DATE] at 11:55 AM, the resident's PHL surrogate provided photographs of the pill packet sheets given to the resident at the time of discharge from the facility. The photos showed two large pill packet sheets, stapled together with the flat label sides facing in. One pill packet sheet was labeled with Resident #1's name, and the other with Resident #2's name. During a telephone interview with pharmacist #7 on [DATE] at 1:41 PM, they stated Residents #1 and #2 had discharge medications sent to the facility on [DATE]. Discharge medication orders were always packaged separately in different bags and were not stapled together by the pharmacy. During a telephone interview with RNS #9 on [DATE] at 11:53 AM, they stated when receiving pharmacy orders, they checked the bag, signed the packing slip and brought the medications to the office. When accepting medication deliveries off-hours, the RNS did not reconcile the orders against the resident's records, as the Nurse Manager would be responsible to do so the following day and/or prior to discharge. During a follow-up telephone interview with RN Manager #1 on [DATE] at 1:39 PM, they stated they were unaware of how Resident #2's medications were in Resident #1's pharmacy bag and did not recall seeing a second pharmacy bag. RN Manager #1 stated they did not review the medications in the bag prior to giving them to the resident and did not staple any pill packet sheets together. They stated they were unaware of how the discharge paperwork for Resident #2 was included with Resident #1's paperwork. The RN Manager #1 stated it was their responsibility to verify the medications and orders prior to sending them home with the resident and they did not do so. During a telephone interview with the DON on [DATE] at 2:15 PM, they stated they were unaware Resident #2's medications were sent home with Resident #1. RNS #9, who received the pharmacy order, was expected to verify the correct medications as well as RN Manager #1, who discharged the resident on [DATE]. The medications and discharge information should always be verified. If a resident lacked capacity or had a language barrier, nursing staff were expected to talk to the representative picking up the resident at the time of the discharge to ensure the correct medications were provided and the family/representative knew what they were. During a telephone interview with the facility's attending physician (physician #10) on [DATE] at 1:27 PM, they stated the resident had [CONDITION(S)], was not on [CONDITION(S)], and taking added potassium could place the resident at risk of [CONDITION(S)] and [CONDITION(S)]. A normal potassium level was between 3.0 to 4.4 mmol/L and if potassium, was 7.4 mmol/L, the resident would need urgent care. The physician stated they expected nursing to review all medications and instructions with the resident at the time of discharge. If the resident was unable to understand, the caregiver should be fully informed of the medications and instructions. 10NYCRR415.11(d)(3)

Based on observation, record review, and interview during the abbreviated survey (NY 179) conducted on [DATE], the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed. Specifically, on [DATE], a resident with a diagnosis of dementia and depression, and identified as a risk for elopement following exit seeking behaviors, was able to leave the facility undetected by staff through a third-story window, fell approximately 30 feet, and was found on the ground outside of the facility with fatal injuries. At approximately 10:00 PM on [DATE], the resident was noted to have barricaded themselves in their room when a nurse called to them to open the door. The resident opened the door very slightly and refused their medications. The door remained barricaded throughout the night and staff did not attempt to force the door open. Shortly after 5:00 AM on [DATE], a nurse went to the resident's door to bring their medications and could not open the door. The door was forcefully pushed open, and the resident was not found in the room. The window was open, and the resident was seen lying on the ground outside, approximately 30 feet below the window. The resident sustained traumatic injuries including multiple fractures and a head injury. The resident was transported via emergency medical services (EMS) to the hospital where they expired. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to Resident #1 and placed 22 residents with wandering behaviors at risk for serious harm to resident health and safety. Findings include: The undated facility Wandering and Elopement Protocol documents: - the purpose of the protocol is to define the responsibilities and interventions of staff and visitors when a resident has been assessed as an Unsafe Wanderer or has a potential for Elopement. - Residents assessed as having a potential for unsafe wandering and/or elopement will be observed for exit seeking behavior, packing suitcases, bags, clothing, possessions, visual monitoring of exits or elevators, verbalization of a desire to leave, go home or how to leave the facility or a disregard for facility policy related to restricted areas, smoking policy, pass policy, etc. - Staff will document observations in the medical record and in the Wander Risk Assessment form. - The comprehensive care plan (CCP) will be adjusted as appropriate based upon assessment and with family input to address causative factors. - All members of the Interdisciplinary team are responsible to know the established plan of care and to report resident responses (positive and negative) as related to the plan of care. - The CCP will be based on the assessment and individualized to the resident and will include activities and interventions that are relevant to the resident's interests, backgrounds and exhibited behaviors. - Consideration for developing the CCP include to identify physical, social, or psychological driving forces that may enhance the resident's desire to wander such as pain, feelings of loss or abandonment, looking for family/pets etc., and evaluate environment for potential hazards for the resident. - Potential interventions include but are not limited to intermittent supervision, utilization of the Wanderguard Bracelet System, and frequent visual location checks. Policies were requested for resident safety checks and/or resident supervision and facility policies and procedures were not supplied. Resident #1 had diagnoses including dementia, [CONDITION(S)], and depression. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was intact, they rejected care and wandered, and required supervision with activities of daily living (ADL). Wanderguard (bracelet to alert staff when a resident approached the elevator or exit doors) applied to resident The [DATE] physician's order documented the resident was to wear a wanderguard due to high risk for elopement. The [DATE] comprehensive care plan (CCP) documented the resident was a native Spanish speaker, preferred to speak Spanish, had limited physical mobility, history of aggressive behaviors including anger and ineffective coping skills, and was at risk for elopement related to wandering, attempting to leave the unit unattended, and wanting to go home. Interventions included the resident was dependent on staff for locomotion using a wheelchair, wanderguard was placed on the wheelchair, and staff were to distract the resident from wandering by offering diversions, activities, and food. The CCP documented staff were to check placement of the wanderguard every shift and were to monitor the resident's location. The frequency to monitor the resident's location was not documented on the CCP. The CCP was updated on [DATE] and documented the resident was independent with transfers, bed mobility and ambulation in room and corridor's and no longer used the assistive devices. The resident was independent with wheelchair mobility. Documentation of the resident's safety checks were requested and none were provided. The [DATE] at 10:31 AM, registered nurse (RN) Manager #10's progress note documented a stop sign was placed on the resident's door to stop other residents from entering room. Additionally, the resident had a sign on their door requesting the door to remain closed. The [DATE] Incident Report documented at approximately 11:00 AM, Resident #1 was seen between the double doors on the A South unit (different unit from where the resident resided) and these doors led to the outside. The resident was upset and stated they were leaving and going to [NAME] Rico. The resident grabbed a large clothing rack that was in the hallway, appeared they were going to break the window, and continued to express a desire to go to [NAME] Rico. The resident previously refused placement of a wanderguard on their leg so the wanderguard was placed on their wheelchair. After speaking with Spanish speaking staff that date, the resident agreed to the wanderguard being placed on their left ankle (wanderguard was applied to the wheelchair previously on [DATE]). The [DATE] at 1:02 PM RN Manager #10's progress note documented the resident required 24 hour a day supervision, had a wanderguard, and continued to express the desire to return home to their native country. A stop sign remained on their door as well as a sign to keep their door closed. The [DATE] at 9:28 PM, RN #12's progress note documented the resident was aggressive, threw medications, and could not be redirected. The resident was talking word salad (incoherent speech), was hallucinatory, and the plan was to check on the resident routinely. The [DATE] at 2:47 AM, licensed practical nurse (LPN) #2's medication administration note documented the resident's door was blocked when attempting to check pulse oximetry every four hours and vital signs every shift as ordered. The [DATE] at 5:11 AM, LPN #2's medication administration note documented the resident had a thing in their room in front of the door and the door could not be opened when they were attempting to give a morning medication. On [DATE] at 10:49 AM, the resident's room door was observed. The resident had a sign on the door to keep door closed that was written in both English and Spanish. The Director of Nursing (DON) stated in an interview at that time, the resident posted the sign on their door. During the observation, the Corporate Vice President demonstrated how they thought the resident used a wheelchair brake extender in place of the window crank to open the window. They stated no window crank was found in the room after the resident exited but the Corporate Vice President demonstrated how the wheelchair brake extender fit on the window (where the crank would go) and demonstrated opening the window. The window opened approximately 6 inches and stopped opening when it reached a silver screw that was in the window frame. The Corporate Vice President stated at that time, the resident had to apply a little bit of force to the window for it to move past the screw and the Corporate Vice President demonstrated this by applying a little force to the window. When this was done, the window opened up all the way and bypassed the screw that was in the window frame. The call bell box on the wall was cracked and damaged and there was no call bell cord attached to the box. The [DATE] at 11:19 AM, RN Supervisor (RNS) #9's progress note (entered in the medical record on [DATE] at 4:43 AM as a late entry) documented that RNS #9 was called by LPN #2 at 5:30 AM and was told the resident barricaded themselves in their room. RNS #9 relayed the information to RNS #8 (who was covering the resident's unit). A call was later received from RNS #8 who told RNS #9 the resident was gone and may have gone out the window. RNS #9 documented they immediately ran to the courtyard to find the resident lying on their back under a tree. The resident was conscious, responding to verbal stimuli, and that RNS #9 stayed with the resident while staff called 911. The [DATE] facility's investigation documented: - The Resident #1 was alert and oriented and had poor safety awareness. - On [DATE] on the evening shift, the resident pulled the call bell from the wall twice and it was plugged back in. - LPN #3 attempted to give HS (hour of sleep) medications on [DATE] and the resident's door was barricaded. The resident was care planned for staff to reapproach if they had behaviors. When LPN #3 reapproached after some time, they were able to get the resident to open the door to visualize Resident #1. The resident refused their medications. - LPN #3 (evening shift) reported to the night shift LPN (LPN #2), the resident was behavioral and per the resident's care plan, was given time and reapproached. - LPN #2 was going to attempt vital signs and knowing the resident's behaviors and that the resident barricaded themselves in their room, documented they refused vital signs. The staff (the report did not specify which staff) reported it was normal for the resident to keep their door closed for privacy. - Staff did not hear any commotion in the resident's room through the night shift and the resident's call bell did not ring. - LPN #2 went to administer [MEDICATION(S)] ([CONDITION(S)] medication) at 5:11 AM on [DATE] and was unable to open the door. - LPN #2 notified RNS #8 and RNS #8 was able to push open the door. The resident was not in the room and the window was open. - Staff (report did not specify who) saw the resident on the ground outside and the resident was breathing and speaking Spanish. 911 arrived shortly afterwards. - Upon review of the room, the facility determined the resident had taken a wheelchair brake extender off their wheelchair and used it as a crank to open the window (the facility could not find the crank and could not determine if it fell out the window). The window had a restrictor on it to prevent the window from opening too far and it looked like enough force was applied to pass the limiter. The resident tied a cable wire and call bell together to create a rope and hung it out the window. The report documented the call bell adapter and unit in the room appeared to be broken from tampering by the resident. It was not in place, and it was not alarming which it should be. On [DATE] hospital report documented Resident #1 presented to the hospital after jumping from a window several stories high after barricading themselves in their room. The resident was found with a right leg tibia/fibula (lower leg bones below knee) open fracture (bone protruding through skin), comminuted (pulverized) T12 ([MEDICATION(S)] spine) and L1 (lumbar spine) burst fracture, subdural hematoma (brain bleed), T11 and L2 fracture, pulmonary (lung) contusions, fractures of the coccyx (tailbone) and pubic rami (pubic bone) with retroperitoneal (behind the abdominal cavity) bleed and left leg displaced comminuted fracture of the mid to distal (lower portion) of the femur (thigh bone). The resident expired shortly after admission. On [DATE] at 1:45 PM, CNA #7 stated in a telephone interview, they worked the evening shift on [DATE] and was assigned to Resident #1. The resident had behaviors and could be aggressive. The resident was Spanish speaking, communication was difficult at times and there were Spanish speaking staff in the building to assist. CNA #7 stated during the evening shift on [DATE], the resident pulled the call bell out of the wall twice. The CNA stated they never knew the resident to do that before, and the resident's behavior was calm. At 10 PM, LPN #3 stated to CNA #7 that LPN #3 would do the last safety check on the resident because they were going to give them medications. CNA #7 stated LPN #3 found the resident's door barricaded but was able to get the resident to open it and saw the resident at the door. CNA #7 stated they recalled one other time the resident barricaded their door and did not recall if that was reported to anyone. On [DATE] at 12:33 PM, LPN #3 stated in a telephone interview, they worked the evening shift on [DATE]. The resident pulled the call bell out of the wall twice earlier in the shift and it was replaced and the resident was educated not to pull it out of the wall. The resident's medications were due at 6 PM, 9 PM, and 10 PM but LPN #3 stated they always gave the medications at once so the resident would not refuse. LPN #3 stated they tried to give the resident their medications around 10 PM on [DATE]. The resident always blocked their door so other residents could not enter and the resident would always come to the door and open it when LPN #3 knocked. On [DATE], the resident blocked the door and LPN #3 pushed the door open part of the way at around 10 PM. The resident came to the door and refused their medications and closed the door. LPN #3 stated their shift ended after 10 PM and they reported to LPN #2 the resident refused their medications and their door was blocked. LPN #3 stated they did not report this to a Supervisor in the past and did not report it to the Supervisor on [DATE]. On [DATE] at 1:18 PM and [DATE] at 11:22 AM, CNA #5 stated in telephone interviews, they worked [DATE] on the night shift and was assigned to Resident #1. LPN #2 reported to them the resident barricaded their door on the evening shift. During the start of CNA #5's shift, there was a lot going on including a fire alarm that took 45 minutes to deal with and then LPN #2 locked the medication room keys in the medication room. CNA #5 stated both RNS #8 and 9 were on the unit helping with the keys being locked in the medication room and CNA #5 did not see either RNS #8 or 9 check the resident's room. CNA #5 stated the CNAs were responsible to do safety checks on the residents 3 times a shift but they never did safety checks on the resident. CNA #5 stated they were told not to do the checks because the resident would become violent. CNA #5 stated they were told the nurse would check the resident when they gave medications. On [DATE] at 9:31 AM, LPN #2 stated in a telephone interview, they came on duty on [DATE] at 10:15 PM and worked the night shift, and: - when the shift started, LPN #3 (who worked the evening shift) reported Resident #1 barricaded themselves in their room and the Supervisor was aware. - LPN #2 did not notify the night Supervisor of the resident's door being barricaded because LPN #3 reported they already had. - LPN #2 thought it was strange when they did not hear anything further that night from the Supervisor but there were times when the Supervisor did not get back to them. - Certified nurse aides (CNA) were to check on residents every 2 hours during the night but they did not check on the resident because they were told by multiple Supervisors to leave the resident alone if they were not acting out at night. - LPN #2 stated the staff could not ensure the resident was safe when they did not check on them during the shift. - At 2:47 AM on [DATE], when LPN #2 entered a note the resident refused vital signs, and documented the resident's door was blocked and that the LPN did not attempt to get into the room at that time. - The first time LPN #2 checked on the resident on the night shift was around 5:10 AM on [DATE] when they went to give a morning medication and found the resident's door barricaded. - At 5:11 AM, LPN #2 notified RNS #8 the door was barricaded and RNS #8 responded within 5 minutes. RNS #8 pushed open the door and said the resident was missing. On [DATE] at 10:51 AM, RNS #9 stated in a telephone interview, they worked the night shift on [DATE] and was responsible for the 918 building and RNS #8 was responsible for staffing and the 906 building (the building where the resident resided). RNS #9 was in the office alone when LPN #2 called at around 5:30 AM on [DATE] and reported the resident's door was barricaded and had been all night. RNS #9 did not respond to the unit because they had their own work to do and when RNS #8 returned to the office from a unit about 10 minutes later, RNS #9 told RNS #8 about the phone call. RNS #8 stated to RNS #9 they were going to check the resident because they could have hurt themselves. RNS #8 left for the unit and then called RNS #9 stating the resident was not in their room and the window was open. RNS #9 ran to the courtyard where it was dark and pouring rain. A CNA was in the resident's window and spotted the resident on the ground on their back under a small tree. RNS #9 stated the resident was breathing and mumbling in Spanish and RNS #9 stayed with the resident until the ambulance arrived. RNS #9 stated they would have expected the night shift LPN to call them at the beginning of the shift so they could have checked the resident. RNS #9 stated that they and RNS #8 were on the unit during the shift and no one told them the resident was barricaded in their room. The resident put stuff in front of their door in the past and RNS #9 stated that they and RNS #9 stated they never told staff not to do safety checks on the resident and staff had to do safety checks to ensure residents were safe. On [DATE] at 11:14 AM, RNS #8 stated in a telephone interview, they started their shift as the evening Supervisor on [DATE] at 7:00 PM and worked until 7:00 AM on [DATE]. RNS #8 stated they were on the resident's unit frequently on the evening shift and LPN #3 never notified them the resident's door was barricaded. RNS #8 stated that they and RNS #9 were on the resident's unit from 1:30 AM to 3:00 AM assisting LPN #2 with an issue with the medication room keys and LPN #2 never told them the resident's door was barricaded. Between 5:00 AM and 5:30 AM on [DATE], RNS #8 stated they were in a COVID-19 positive resident's room and was not allowed to carry their cell phone in that room so when RNS #8 returned to the Supervisor's office, RNS #9 told them the resident had barricaded themselves in their room. RNS #8 stated they immediately went to the unit. RNS #8 pushed the resident's door open and found a wheelchair and bedside table behind the door. The resident was not in bed or the bathroom and they noticed the window open. RNS #8 called RNS #9 who went to the courtyard and found the resident. RNS #8 stated they had spoken to the resident's family member twice in the past and the family member never stated to RNS #8 that the resident said they would go out the window and RNS #8 had never heard the resident had barricaded their door in the past. RNS #8 stated safety checks were required to ensure a resident was not hurt or on the floor and they expected them to be completed. RNS #8 stated that they expected to be notified at the time the resident barricaded their door. On [DATE] at 5:03 PM, the resident's family member (who was the appointed health care proxy although the health care proxy was not activated as the resident was their own decision-maker) stated in a telephone interview the resident lived with them for 3 years and came to the facility when they could no longer care for the resident at home due to the resident's wandering. The family member stated one day the resident left and returned hours later and the family member told them they could not leave without anyone knowing. The family member reported after that it was a battle as the resident continued to leave unattended and one day, the resident fell in the road and a passerby called 911 and the resident went to the hospital. At the hospital, it was decided the resident could not live in the community anymore. The resident was very angry with them that they were put in the facility. The facility called the family member daily and reported behaviors and difficulty controlling the resident. The family member stated they told the staff the resident did not want to be at the facility and recalled a telephone conversation with staff a few months ago when they could hear the resident yelling in the background. The resident was yelling in Spanish I'm going to go out the window, watch me. The resident's family member told the staff exactly what the resident said and asked them to be sure the windows were locked. They did not recall who the staff were. On [DATE] at 11:47 AM, RN Manager #10 (Manager of the resident's unit) stated in a telephone interview: - safety checks were completed every 2 hours on all residents and staff knew to check residents with exit-seeking behavior more frequently though that was not necessarily in the CCP. - When a resident barricaded themselves in their room, RN #10 expected staff to notify the RN so an assessment could be completed and the provider could be notified. - The resident kept to themselves, stayed mostly in their private room, and had aggressive behaviors. When the resident refused care or medications, the CCP documented staff were to reapproach at a later time. - The resident's door was kept shut because the resident would get upset when other residents wandered in their room. Staff should do safety checks when the door was open or shut. - The resident had a wanderguard applied to their wheelchair in ,d+[DATE] because they kept finding the resident at the elevators. The resident would not wear it on their body at that time. In ,d+[DATE], the resident was found on a different floor and was trying to exit to the outside and at that time, the resident agreed to wear a wanderguard on their ankle. - The resident regularly stated they wanted to leave the facility and return to [NAME] Rico though RN #10 never heard that the resident threatened to go out the window. - RN #10 stated they were not aware the night shift staff were not completing safety checks when the resident was sleeping and that was not acceptable. - RN #10 stated they were not aware LPNs 2 or #3 did not report the resident barricading their door to the Supervisor at 10 PM and expected the LPN to notify the RNS immediately. On [DATE] at 12:43 PM, the attending physician stated in a telephone interview, the resident had dementia with behaviors, they were non-compliant and Spanish speaking. The resident was not very communicative and difficult to get information from. When the resident barricaded their door, it was a serious situation that needed to be addressed right away. The Administrator and Security should had been notified to determine what was going on because they could not be sure what the resident was doing behind the door. It was not acceptable that the staff on the night shift did not complete safety checks and that it was not acceptable when the Supervisor was not notified of the resident's barricaded door. On [DATE] at 10:33 AM, the Administrator stated in a telephone interview when a resident barricaded their door, they expected the RN to be called for an assessment and a plan to be implemented addressing the behavior. For a resident that barricaded themselves, they expected the RN and the physician to determine the appropriate interventions. The resident did not actually barricade their door using only a wheelchair placed behind it. If LPNs #2 or 3 were not able to access the door, then the situation should have been escalated so safety could be ensured. It was not normal to not round on a resident and residents were typically rounded on twice per shift. -------------------------------------------------------------------------------------------------------- The Immediate Jeopardy was removed on [DATE] based upon the following: - All windows were audited to ensure they did not open further than 6 inches. - All residents with wandering behaviors were assessed to ensure all care planned interventions were in place. - All registered nurse (RN), licensed practical nurse (LPN), and certified nurse aide (CNA) staff were educated immediately on dangerous behaviors, including barricading of doors, the need for assessment by the RN and potential interventions including 1:1 staff. Education included when the RN did not respond to the initial call, staff would call the RN again, or follow the appropriate chain of command for notification. 10 NYCRR 415.12(h)(1)

Based on interview and record review during the abbreviated survey (NY 759), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #4). Specifically, Resident #4's [MEDICATION NAME] ([MEDICAL CONDITION] medication) was discontinued by the physician without a replacement dose, laboratory review, or other monitoring. The resident was subsequently hospitalized with [MEDICAL CONDITION] coma (severe [MEDICAL CONDITION]) and required intravenous (IV) [MEDICATION NAME] ([MEDICAL CONDITION] medication). This resulted in harm to Resident #4 that was not immediate jeopardy. Findings include: The undated Drug Regimen Review-Monthly policy documents consultant pharmacists shall perform Medication Regimen Reviews for each resident at least monthly. The review shall be performed by evaluating the medical record of each resident, which contains the current Medication regimens documented on the most recent physician's orders [REDACTED]. Resident #4 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/19/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition. The 10/10/19 hospital discharge summary documented the resident had a history of [REDACTED]. The 10/10/19 physician order [REDACTED]. The 10/11/19 nurse practitioner (NP) #4's History and Physical documented the resident had a history of [REDACTED]. The NP planned to re-check labs again in 4-6 weeks. The 10/15/19 physician #3's History and Physical documented he concurred with the NP's 10/11/19 evaluation. The resident had a history of [REDACTED]. The 11/11/19 NP #4's progress noted documented the resident's TSH had been recently checked, was mildly elevated, and the [MEDICATION NAME] dose was adjusted. The NP recommended checking a [MEDICAL CONDITION] function lab in 4-6 weeks. The 11/11/19 physician order [REDACTED]. The November 2019 Medication Administration Record [REDACTED]. LPN #8 administered the medication 12 times. The 12/2019 MAR indicated [REDACTED]. The 12/3/19 physician #1's order documented the resident's [MEDICATION NAME] was discontinued. There was no corresponding progress note documenting the discontinuation of [MEDICATION NAME]. The 12/3/19 registered nurse (RN) Manager #6's progress note documented the resident was adjusting to their new unit. There was no documentation regarding a medication change. The 12/2019 staffing sheet documented LPN #8 worked the night shift on 12/1, 12/3, 12/4, 12/5, 12/6/19 and LPN #9 worked the night shift on 12/8/19. LPN #8 worked the first shift after the resident's medication was discontinued. The 12/14/19 nursing progress note documented the resident was diaphoretic (excessive sweating), pale, and bilateral lung sounds with rhonchi (coarse breathing sounds) in the bases bilaterally. The on-call provider was notified and blood work, urine culture and chest x-ray were ordered. The resident's vitals were checked; the resident's finger stick was 261 milligrams per deciliter or mg/dL (normal is less 140 mg/dL when not fasted), blood pressure was 92/55 (lower than resident's normal), heart rate was 77 (higher than resident's normal), and temperature was within normal limits. The 12/15/19 nursing progress note documented the resident continued to present poorly. The resident's blood work indicated no elevation in white blood cell count (did not indicate an infection). The resident's chest x-ray indicated a left lower lobe infiltrate. STAT (immediate) labs were ordered including urine and sputum for legionella, and an antibiotic for potential pneumonia was initiated. The resident had an x-ray of the sinuses which indicated some degree of chronic sinusitis with no evidence of acute sinusitis. The 12/23/19 nursing progress note documented the resident had a fall. The 12/23/19 nursing progress note documented the resident's lab results were reviewed with the physician and were consistent with previous draws and there were no changes at that time. The 12/23/19 lab results report did not include [MEDICAL CONDITION] function tests. The 12/26/19 Medication Regimen Review by pharmacist #7 documented the resident's medications were reviewed. The pharmacist recommended to review the resident's [MEDICATION NAME] Nasal Spray and there were no recommendations regarding the resident's [MEDICATION NAME]. The 12/27/19 nursing progress note documented the resident was observed to be sweating and the RN was notified. The 12/27/19 RN Manager #6's progress note documented the resident was severely diaphoretic and [MEDICAL CONDITION] (faster than normal heartbeat). The resident was hypotensive (low blood pressure) and heart rate was originally 249 beats per minute (normal is 70-100). The resident's heart rate ranged from 50 to 149. The NP was called to assess the resident and the resident was transferred to the hospital. The 12/27/19 NP #10 progress note documented the resident had [MEDICAL CONDITION] (low blood pressure) and diaphoresis (excessive sweating) with an erratic heart rate. The resident was sent to the hospital to rule out [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The 12/27/19 hospital Discharge Summary documented the resident was seen for chest pain and sent back to the facility. The report documented no changes to the resident's medications. A current medication list was not documented. The 12/29/19 nursing progress note documented the resident had another episode of [MEDICAL CONDITION] with diaphoresis. A chest x-ray was ordered and a request for the hospital discharge records from 12/27/19 was made. The 12/30/19 RN Manager #6's progress note documented the RN spoke with the resident who stated they were feeling fine. The resident stated they did not have a regular cardiologist that they followed for [MEDICAL CONDITION] (abnormal heart rate), and the resident was agreeable to a referral. The 12/30/19 physician #1's progress note documented the resident was seen for [MEDICAL CONDITION] (abnormal heart rate) with rapid ventricular response. The resident was sent to the hospital and returned (12/27/19) without medication changes, then had another episode of [MEDICAL CONDITION](rapid heart rate) and reduced level of responsiveness. The physician started [MEDICATION NAME] (blood pressure medication) on that date. The progress note documented the resident's weight was up almost 60 pounds in an unspecified time frame with a history of diastolic heart failure. The physician documented the resident's medical condition would be monitored. The 12/31/19 lab results report did not document the resident's [MEDICAL CONDITION] levels were checked. The 1/4/20 nursing progress note documented the resident was very diaphoretic and lethargic. Heart rate was checked and found to be 35 beats per minute (low). The NP was notified, and the resident was transferred to the hospital. The 1/4/20 Resident Transfer form documented the resident was being sent to the hospital for a low heart rate, lethargy, and diaphoresis which was sudden onset. The 1/4/20 hospital History and Physical documented the resident was admitted for [MEDICAL CONDITION] coma versus septic shock from complex [MEDICATION NAME] (inflammation of the bladder). The resident had a documented history of primary [MEDICAL CONDITION]; during their previous admission the resident was discharged on 150 mcg of [MEDICATION NAME] per day, and the facility's orders and Medication Administration Record [REDACTED]. The resident's TSH level was 48.1 mU/I with a free TSH 4 ([MEDICAL CONDITION] level) of 0.14 mcg/dL (micrograms per deciliter, normal range is 4.5 to 11.2 mcg/dL). The 1/11/20 hospital Discharge Summary documented the resident was admitted to the hospital with [REDACTED]. On admission, the resident was found to be with [MEDICAL CONDITION] coma with severe [MEDICAL CONDITION] with a TSH of 48.1 and a free TSH 4 of 0.14 and was loaded with intravenous (IV) [MEDICATION NAME] and given IV [MEDICATION NAME] for [MEDICAL CONDITION]. The resident improved during the hospital stay and eventually transitioned off IV [MEDICATION NAME] to oral [MEDICATION NAME] of 150 mcg per day. The 1/12/20 readmission History and Physical completed by the facility's Medical Director documented the resident was readmitted after a hospital stay from 1/4/20-1/11/20. The resident had abrupt diaphoresis, unresponsiveness, and [MEDICAL CONDITION] (low heart rate) due to [MEDICAL CONDITION] (severe [MEDICAL CONDITION]) which was [MEDICATION NAME] supplemented. During their hospital stay, the resident received IV [MEDICATION NAME]/[MEDICATION NAME] with eventual transition of [MEDICATION NAME] by mouth. The resident was to be on [MEDICATION NAME] 150 mcg once per day. During an interview on 10/27/20 at 2:18 PM, physician #1 stated he had reviewed the orders and the resident's [MEDICATION NAME] was discontinued without checking a TSH or entering a replacement dose. The physician stated he was unsure how to enter orders in the electronic medical record (EMR) but stated he was comfortable discontinuing orders. He reviewed residents' medication orders to make sure they were appropriate and if he wanted new orders entered, he told the RN Unit Manager who would enter the orders for him. He discontinued orders on his own. He thought he must have given a verbal order to RN Manager #6 when he discontinued the resident's [MEDICATION NAME], but he did not have any documentation of that. The physician stated the resident's hospitalization was unnecessary and although he tried to reduce the medication load for most of his residents, he would not discontinue [MEDICATION NAME] without a TSH or trying a lower dose first. During an interview on 11/2/20 at 12:14 PM, RN Manager #6 stated if a physician wanted a medication change, they would enter it in the Electronic Medical Record (EMR) themselves or provide a verbal order to the RN who would read back to verify. The incident with the resident came to light when the Resident #4'2 family member came to the facility and asked to see the resident's medication list. The family (was told by the hospital the resident was not receiving [MEDICATION NAME]. After speaking with the family, she told the Director of Nursing (DON) and Assistant Director of Nursing (ADON) and physician #1. There had been no change in the process for ordering medications after the incident with the resident. During an interview on 11/2/20 at 1:01 PM, the DON stated physicians typically gave verbal orders to the RNs to enter in the Electronic Medical Record (EMR). Physicians could enter orders themselves, but most did not. Physicians also documented progress notes with their recommendations. Resident #4's family approached RN Manager #6 about the resident's [MEDICATION NAME], and RN Manager #6 came to the DON. The facility checked the medical record, the resident received [MEDICATION NAME] since admission, and it was discontinued at the beginning of December 2019. The DON stated, when he spoke with physician #1, physician #1 stated he had inadvertently discontinued the medication. The facility also had pharmacy reviews done which would provide additional oversight to the medications ordered. During an interview on 11/6/20 at 2:56 PM, pharmacist #7 stated medication regimen reviews were completed on residents' current orders. Medications that were discontinued since the previous medication regimen review would not be reviewed. Physicians had the overall authority to continue or discontinue medications and discontinued several medications each month. During an interview on 11/19/20 at 8:14 AM, LPN #8 stated when she noticed a medication was discontinued, she tried to check and see if there were physician notes documenting the change. She did not recall any medication changes for the resident. During an interview on 11/19/20 at 12:23 PM, LPN #9 stated the clinical dashboard alerted the nurses to any changes in residents' medications or condition. Medication passes were documented on the computer screen; if a medication was discontinued, there would be a red X by it on the screen. She stated if the resident's [MEDICATION NAME] was the only medication the resident had ordered on that shift, it would not show up on the screen with the red X by it, so someone may not notice it was discontinued. The LPN could not recall the resident's medication change. During an interview on 11/19/20 at 12:45 PM, RN Manager #6 stated monthly medication reviews were conducted by the pharmacist. The physician also reviewed the medication regimens during their scheduled visits. She stated the facility did not do a double check of medication orders monthly. During a follow-up interview on 11/19/20 at 2:14 PM, the DON stated that the facility did not have a monthly medication change over process. Medication renewals and re-ordering was done through the electronic medical record and whenever a medication was needed. For non-narcotic medications, such as [MEDICATION NAME], the medication was sent by the pharmacy monthly until the medication was discontinued in the electronic medical record. He stated the only medication review process was completed by the consultant pharmacist. 10NYCRR 415.12

Based on observation, record review, and interview during the abbreviated survey (NY 862) the facility did not ensure residents were free from abuse and that staff reported abuse immediately to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, - The facility did not prevent Resident #1 from being abused by certified nurse aide (CNA) #1. - CNAs #2 and 3 did not report abuse immediately to facility Administration resulting in CNA #1 taking care of other residents as she was not suspended immediately. This resulted in actual harm that was not immediate jeopardy to Resident #1 of a 3 day hospital admission where she was evaluated and treated for [REDACTED]. The police were notified and the perpetrator was arrested and charged with a misdemeanor. Findings include: The facility's Abuse Reporting and Facility Incident Reporting policy, revised 10/2019, documented all personnel are required to report incidents of resident abuse or suspected incidents of abuse to their immediate Supervisor. Resident #1 had [DIAGNOSES REDACTED]. The 7/28/2019 Minimum Data Set (MDS) assessment documented the resident was not able to complete the Brief Interview for Mental Status (BIMS) and a staff assessment of cognition was not documented. The resident required extensive assistance from one person with activities of daily living (ADL). The resident did not exhibit behaviors and did not reject care. The 10/27/2019 MDS documented the resident's cognition was severely impaired. The 10/20/2019 at 6:24 AM, licensed practical nurse (LPN) #4's progress note documented when she arrived at the unit, she heard loud banging and yelling from the resident's room. She found the resident had a bruised area to the left side of the face and she was yelling out. The registered nurse Supervisor (RNS) was notified. The facility's incident report intiiated on 10/20/2019, documented a reportable incident of inappropriate physical contact resulting in injury or likely to harm a resident. Statements obtained by the facility included: - Certified nurse aide (CNA) #3's statement dated 10/20/2019, documented on the 11 PM to 7 AM shift on 10/20/2019, she witnessed CNA #1 hit (the resident) in the face with a wet towel. She immediately called RNS #6, he picked up the phone, said he was busy and could not talk, and hung up. She called right back, and RN #6 did the same thing. During the remainder of the shift, the resident screamed that someone hit her, was combative, and yelled out until CNA #3 left the facility at 7 AM. - CNA #2's statement dated 10/20/2019, documented on the night shift on 10/20/2019, she was in Resident #1's room caring for her roommate when CNA #1 was caring for Resident #1. She heard Resident #1 yell for CNA #1 to stop hitting her, she heard a loud slap, and Resident #1 yelled ooh you hit me in the face. CNA #1 asked CNA #2 for help with Resident #1's brief and CNA #2 assisted. At that time, she saw Resident #1's face was bleeding, and CNA #1 told her the resident scratched herself in the face. CNA #2 left the room and told CNA #3 the resident was bleeding. CNA #3 told CNA #2 that CNA #1 hit the resident in the face with a wet towel and CNA #3 called the Supervisor. - CNA #1's statement dated 10/20/2019, documented on 10/20/2019 (time not specified), the resident was resistive to care when she started washing her. The resident was upset, swinging, hitting, and kicking. There was a lot of commotion and the resident got a scratch on her face during the commotion. - LPN #7's statement dated 10/21/2019, documented on 10/20/2019 (time not specified) none of the staff reported anything to her about the resident during the night shift. - LPN #4's statement dated 10/20/2019, documented on 10/20/2019 at 6 AM, she arrived to the unit and at no time did anyone tell her they witnessed abuse. - Assistant Director of Nursing (ADON) #5's statement dated 10/21/2019, documented on 10/20/2019 at 11:33 AM, she was called by CNA #3 who asked her to come to the resident's unit and speak with her. At 11:38 AM, she received a call from LPN #4 asking her to come to the unit to speak the resident's family member who was upset. At the time of the calls, she did not know the two requests were related. She went to the unit and spoke with CNAs #2 and 3 who reported the allegation of abuse. She then spoke with the resident's family member and assessed the resident. She documented she found the resident with a 5.5 centimeter (cm) x 2 cm bluish-purple bruise on her left temple at the hairline and multiple purplish-blue bruises and small scratches on her bilateral hands and wrists. The resident did not complain of pain but did displayed non-verbal signs of pain such as grimacing, wincing, and low moans when bilateral arm dressings were applied. The family requested the resident be sent to the hospital. The investigative summary documented CNAs #2 and 3 did not report abuse timely and did not contact their direct supervisor when the building Supervisor was not available. The 10/20/2019 hospital RN's progress note documented at 1:57 PM, the resident arrived from the nursing facility as the family went to visit and noted bruising on her bilateral hands, an abrasion to the left cheek, and complaints of neck pain. The family reported a staff member at the nursing facility admitted to assaulting the resident. The 10/20/2019 hospital physician's progress note documented the assessment was alleged elder abuse and the resident also had a facial contusion and bilateral hand contusions. The hospital records documented the resident was transferred back to the nursing facility on 10/23/2019 following a 3 day hospitalization where she was evaluated and treated a facial contusion, bilateral hand contusions, neck pain, and a urinary tract infection. CNA #3 was interviewed on 10/31/2019 10:25 AM, and stated the incident occurred on the night shift on 10/20/2019 when she was working with CNAs #1 and 2. She stated the resident liked to sleep late so they normally did not get her up on the night shift and she did not know why CNA #1 tried to wake the resident up and do her care. At around 6:30 AM, she went into Resident #1's room where CNA #1 was caring for Resident #1 and CNA #2 was caring for her roommate. As she was leaving the room, she saw CNA #1 smack Resident #1 in the face with a wet towel. CNA #1 and Resident #1 were struggling and she heard CNA #1 use foul language and tell Resident #1 to keep her hands off her. Resident #1 was not swinging at CNA #1 but was reaching out. She left the room and called RN Supervisor #6. He answered the phone, stated he could not speak, and hung up. She attempted to reach him twice. Later on in the shift, CNA #2 told her the resident's face was bloody. She told CNA #2 that CNA #1 hit the resident in the face. She stated CNA #1 continued to work on the unit for the rest of the shift which ended at 7 AM. For the remainder of the shift, the resident yelled that someone beat her with a hammer and that she was going to hit people with a hammer. She did not report what she saw to the night nurse (LPN #7) or the day nurse (LPN #4) who came in at 6 AM. She said she wanted to tell someone higher up. She left the facility at 7 AM and then returned at around 9 AM to report the abuse to a Supervisor. She stated after she got home, she felt bad for not reporting the abuse, she knew she should have reported it, so she went back to find a Supervisor. In an interview with CNA #2 on 10/31/2019 at 11:30 AM, she stated at around 6 AM on 10/20/2019, she was in Resident #1's room caring for the resident's roommate while CNA #1 was caring for Resident #1. The curtain was pulled so she could not see CNA #1 and Resident #1. Resident #1 did not like to get up early and she heard Resident #1 saying no and that she wanted to sleep. CNA #1 stated she had to wash her up. She heard CNA #1 say stop hitting me to Resident #1. She helped CNA #1 with the resident's brief and saw the resident had a skin tear on her face that was bleeding. CNA #1 told her the resident scratched herself. CNA #2 left the room and told CNA #3 that the resident's face was bleeding. At that time, CNA #3 told her that she saw CNA #1 hit the resident with a wet towel and that she called the Supervisor, but he would not talk to her. She stated CNA #1 continued to work on the unit for the rest of the shift which ended at 7 AM. The rest of the shift, the resident was very combative and yelled that she was hit with a hammer. CNA #2 left the facility at 7 AM and did not report the suspected abuse. After she and CNA #3 left the facility, they felt bad for not reporting the abuse, so they decided to come back and find a Supervisor. They returned at around 9 AM or 10 AM and found a Supervisor to speak to. In an interview with LPN #4 on 11/1/2019 at 11 AM, she stated she came into work at 6 AM and at around 6:10 AM, she heard the resident yelling and tipping things over in her room. She saw the resident had bruising under her left eye. She tried to help the resident and the resident slapped her, scratched her, and hit her with a sneaker. She asked CNAs #1, 2, and 3 why the resident was so out of control and no one told her anything. She called RNS #6 and told him she thought the resident's injuries were self-inflicted because no one reported suspected abuse to her and because the resident was so combative. She stated CNA #2 passed her a note that said, her mouth was bloody before she started banging the nightstand. LPN #4 stated she did not know what the note meant, and CNA #2 handed it to her, did not say anything, and left the facility. The first she heard about suspected abuse was when ADON #5 assessed the resident and told her the resident was hit in the face with a wet towel. CNA #1 was called 12/6/2019 at 1:30 PM. A message was left, and no response was received. In an interview with RNS #6 on 12/6/2019 at 3:10 PM, he stated at the time of the resident's incident, he was the only Supervisor at the facility and was tied up with a violent resident that he was trying to transfer out for psychiatric care. At 6:15 AM, his phone rang, and he tried to answer it. He was unable to talk as the other resident was actively throwing blood on him and ripping at his clothes. He was not aware there was a physical abuse allegation because he did not speak with the caller. He stated the next day, he was questioned by Administration as to why he did not answer his phone. He stated he resigned at that time. A certified letter was sent to CNA #1 on 12/10/2019 and no response was received. In an interview with ADON #5 on 12/18/2019 at 9:40 AM, she stated on 10/20/2019, she was working as the day Supervisor and at around 11 AM or 11:30 AM, she received a call from CNA #3 who stated she wanted to speak to her about resident abuse. Before she could speak to CNA #3, LPN #4 called her and said Resident #1's family was there and wanted to speak to her. At the time, she did not know the two things were related so she told LPN #4 she needed to speak with CNA #3 first because there was an abuse issue and she would see Resident #1's family when she was done. When she met CNA #3, CNA #2 was also present. They reported that morning at 6 AM, CNA #3 witnessed CNA #1 either smack or snap a wet towel in Resident #1's face causing injury. CNA #2 stated she was in the room caring for the roommate, did not see this happen, but heard a slapping sound. She asked the CNAs what they did afterwards, and they said they did not report it and left the facility at 7 AM. She asked them why they did not report it to the LPN as CNA #1 continued to work the rest of her shift and provided care to other residents. She stated they had no explanation except that they felt bad when they got home and decided to come back. She stated after she got their report, she had them write statements and she called the Director of Nursing (DON), Administrator, and Assistant Administrator. After that, she went to Resident #1's room and met with her family. They were very upset because the resident had injuries and they said that CNAs #2 and 3 told them that CNA #1 hit the resident. She assessed the resident and the first thing she noticed was an abrasion to the left side of her face near the eye. The resident also had bilateral circumferential bruising to the wrists that appeared to be new as they were purple/blue and multiple small scratches on her hands and fingers that looked like little cuts. She stated she did not recall all the resident's injuries, but she documented everything she saw that day. After she completed the assessment, she sent the resident out at the family's request. She called and suspended CNAs #2 and 3 for not reporting abuse and attempted multiple times to call CNA #1 to interview her. At some point, the Administrator got ahold of CNA #1 and she agreed to come in and meet with ADON #5, but she did not. CNA #1 stopped at the facility and left her badge at the front desk with a note stating the investigation was not being handled properly and she was resigning. She stated RNS #6 was also suspended as he did not take the calls from the staff members as required. 10NYCRR 415.4(b)

Based on record review and interview during the recertification and abbreviated (NY 135) surveys the facility did not ensure 1 of 9 residents (Resident #343) reviewed for Advance Directives had the right to request, refuse, and/or discontinue treatment. Specifically, Resident #343 was provided cardio [MEDICAL CONDITION] resuscitation (CPR, chest compressions) and revived when a do not resuscitate order (DNR, allow natural death) was in place. Additionally, there was no documentation of consistent staff education on Advance Directives This resulted in actual harm that is not immediate jeopardy to Resident #343. Findings include: The ,[DATE] revised Advance Directive policy documents the facility will ensure that a resident's choices concerning the development of Advance Directives relative to their refusal of medical treatment are followed. - The Health Care Proxy (HCP) will be activated if the individual has lost the capacity to make health care decisions for themselves and a physician order [REDACTED]. - On admission, the resident's Medical Orders for Life Sustaining Treatment (MOLST) form and/or other Advance Directives are reviewed. If a Do Not Resuscitate (DNR) order is present, the order is entered into the electronic medical record (EMR) and the resident gets a red bracelet. If there is not a DNR order a standard black bracelet is placed on the resident. The original MOLST form along with copies of any additional Advance Directives is maintained in a binder on the nursing unit. - Changes to an Advance Directive by the resident must be submitted by notifying the provider or a member of the nursing/social services staff in writing, signed and dated, or by orally notifying the provider in the presence of a witness. The care plan will be modified to reflect any changes and copies of changes to an Advance Directive must be filed in the binder located on the nursing unit. -Advance Directive in-service training programs for the staff are provided annually. Resident #343 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was not assessed, she understood verbal content with clear comprehension and required extensive assistance of two for most activities of daily living (ADLs). The [DATE] physician admission history and physical (H&P) documented the resident was hospitalized from ,[DATE]-[DATE]. The resident had no HCP designated but had a supportive family. The resident was transferred to the facility with cardio-pulmonary resuscitation (CPR, perform chest compressions if the heart stops) status. There was no Medical Orders for Life Sustaining Treatment (MOLST) form. The plan was to admit the resident for rehabilitation, uphold the Advance Directive of CPR and consult social services for clarity regarding Advance Directives. The [DATE] at 9:30 AM the Transfer Out to Hospital form documented the resident was sent back to the hospital for evaluation of her amputation site. The [DATE] at 10:50 AM hospital physician discharge summary documented the resident was treated and was discharged back to facility. Her code status on discharge was full code (perform CPR, insert breathing tube). The [DATE] at 12:27 PM social worker #3's progress note documented an initial interdisciplinary team (IDT) meeting was held with the resident's family members present. The nurse practitioner (NP) discussed the resident's medical situation at length with them. The decision was made to initiate a comfort care MOLST and refer the resident to Hospice (end of life services). A NP progress note dated [DATE] documented a meeting was held with the resident's family and the IDT to discuss the resident's Advance Directives and what her wishes would be. The family decided they did not want a feeding tube or CPR but would accept intravenous (IV) fluids and antibiotics if needed. The MOLST was secured and signed by the NP. The [DATE] at 11:30 AM NP #4 order documented the resident's Advance Directive was DNR/DNI (do not intubate, insert a tube in the airway to assist breathing), and comfort measures. The comprehensive care plan initiated on [DATE] documented the resident/surrogate had decided after informed decision-making that the resident was to be a DNR. The [DATE] at 2:14 AM registered nurse Supervisor (RNS) #7's progress note documented he responded to a code blue (emergency situation) for the resident and CPR was in progress. He checked orders, found an order for [REDACTED]. The [DATE] at 2:21 AM RNS #8 progress note documented she was asked by LPN #5 to evaluate the resident for poor color. Upon entering the resident's room, the resident was not breathing and did not have a pulse. RNS #8 asked LPN #5 what the resident's code status was and LPN #5 told her it was full code. A code blue was called and RNS #8 initiated CPR with the respiratory therapist (RT). She asked to see the MOLST form and was told the resident did not have one. She asked RNS #7 to check the computer and was told the resident had a new order to be a DNR/DNI today. She called the Director of Nursing (DON) and was told CPR measures had to stop because of the DNR order. Emergency medical technicians (EMTs) had already intubated the resident, she had a pulse, and was transferred to the hospital. During an interview with social worker #3 on [DATE] at 11:53 AM, she stated she was contacted by NP #4 on [DATE] when the resident had returned from her hospitalization and was notified the resident was doing poorly. She then contacted the family to have them come in to discuss comfort care and Hospice, because the resident had a full code status in place. A meeting was held the same day with the resident's family, the RN care coordinator, the NP, dietitian, and the social worker. The MOLST included instructions for DNR and comfort care and was completed during the meeting and signed by the NP and the social worker. It was then given to the NP as she wanted to share the MOLST with the physician and explain what was going on. During the meeting RN #10 had her computer with her and updated the EMR to include the DNR status. During an interview with CNA #47 on [DATE] at 11:39 AM, she stated during rounds at 1:00 AM on [DATE], the resident required incontinence care and she and CNA #48 rolled the resident to change her and the resident's color turned awful. CNA #47 called for LPN #5. The CNA did not recall if the resident had a code identifier bracelet on. The nurses from other units reported to the resident's room and she and CNA #48 left. During an interview with CNA #48 on [DATE] at 11:47 AM, she stated she and CNA #47 went in to change the resident's bedding and the resident started turning gray. They called for the nurse and LPNs #5, 46 and RNS #8 were on the unit and came to the room. CNA #48 did not notice if the resident had an identifier bracelet on her wrist. She recalled RNS #8 saying the resident was a full code and they had to start CPR. RNS #8 then started CPR. She and CNA #47 left the room to continue rounds. During interviews with LPN #5 on [DATE] at 10:46 AM and [DATE] at 11:57 AM, she stated she could not recall if the resident had an identifier bracelet on. She stated a resident's code status was supposed to be on the Medication Administration Record [REDACTED]. It was her understanding Resident #343 was a full code. She stated a certified nurse aide (CNA) asked her to look at the resident on [DATE] because the resident's color was not good. She and RNS #8 entered the room and found the resident pale, breathing very shallow, and then she stopped breathing. RNS #8 asked LPN #5 what the resident's code status was, and LPN #5 replied the resident was a full code. LPN #5 left the room to page a code blue and RNS #8 stayed in the room and began CPR. When LPN #5 returned to the room, the RT was performing chest compressions and RNS #8 was providing breaths with an ambu-bag (used to provide ventilation to patients who are not breathing). While CPR was being performed RNS #7 was looking through the resident's chart and found the new order for DNR written that day. The nurses continued CPR after hearing the order was DNR because they had already started and could not stop at that point. When the EMTs arrived, they took over CPR and brought the resident to the hospital. LPN #5 stated she was unaware of the resident's change in code status and it was not communicated to her when she received report from the previous nurse at shift change. LPN #5's personnel record documented she had current CPR certification and she had orientation at the facility. The checklist for orientation did not have a signature by the Advance Directive topic. During an interview with RNS #8 on [DATE] at 3:51 PM, she stated on [DATE] around 1:45 AM, LPN #5 approached her and asked RNS #8 to see the resident as her color did not look good. RNS #8 went to the resident's room and the resident's face and lips were blue and her upper chest looked mottled (spotty/discolored from lack of blood flow). RNS #8 asked LPN #5 when the resident had been found and what her code status was and LPN #5 told her the resident was a full code. The resident was not breathing. She stated RNS #7 and RT #56 came to the room. Staff brought in the AED (automated external defibrillator, delivers a shock to the heart if necessary) and slide board. RT #56 had the ambu-bag and started compressions. RNS #8 pulled down the resident's gown and RT #56 placed the AED pads on the resident, the machine indicated no shock was advised. At that time someone said from the door, she has a red bracelet. RNS #8 did not know what that meant and then another staff said, that means DNR. At the same time another nurse said, no she's a full code. She did not know who made the statements as her back was to them. Other nurses took over CPR and RN #8 went out to get paperwork ready for her transfer. One of the staff followed RNS #8 out to the desk and told her the red bracelet meant the resident had a DNR in place. RNS #8 said she did not know what that meant as she had not learned it in orientation. RNS #8 checked the MOLST binder on the unit and there was not a MOLST in the binder. RNS #7 was also working, had already called 911 after someone had called the code blue overhead. She and RNS #7 looked in the EMR and saw that a DNR order had been entered that day. RN #8 called the DON who directed her to stop CPR. RNS #7 went in to the room and the EMTs were already transferring the resident to a stretcher. The resident was intubated and had a heartbeat. RNS #8's personnel file documented the RN had current CPR certification and that she had been through the facility resident rights and abuse training during orientation to the facility. Her orientation information did not specifically document review of the facility's policy on Advance Directives or DNR/full code identifiers. During an interview with RT #56 on [DATE] at 4:03 PM, he stated that he was working the overnight shift on [DATE]. He was told by a CNA RNS #8 wanted him to go to the resident's room because she was not breathing. He brought the crash cart to the room. The resident was not breathing, and RNS #8 said she was going to start CPR. He checked for a pulse, got the ambu-bag out, and he started ventilation. The resident had been covered with blankets at that time. LPN #5 was standing in the doorway and said to RNS #8 the resident was a full code. RNS #8 then said, yes, she's a full code. When the AED arrived in the room, RNS #8 pulled the sheets down and saw the red bracelet indicating DNR. The RNS #8 then said, she's got a red bracelet and LPN #5 again told RNS #8 the resident was a full code. The RT stated there was confusion as to whether a DNR/DNI was in place. RNS #7 then went to the EMR to determine code status. By the time it was determined the resident was a DNR, CPR had been started and 911 had already been called. RT #56's personnel file did not include proof of CPR certification. His orientation information did not specifically document review of the facility's policy on Advance Directives or DNR/full code identifiers. During an interview with NP #4 on [DATE] at 2:05 PM, she stated when the resident returned to the facility from the hospital on [DATE] she asked the social worker to call the resident's family to discuss Advance Directives. The resident had been alert on her initial admission and after her return from the hospital she had a change in mental status and could not make her needs known. The interdisciplinary team and family were involved in the discussion. During the meeting they initiated a new MOLST for DNR status and comfort measures and reviewed each of the areas on the MOLST. During the meeting RN #10 updated the EMR on her computer to include a new order. RN #10 also changed the resident's identification band to red to identify her new code status. The NP witnessed the RN #10 apply a new red identification band to the resident indicating DNR. The NP stated she then signed the MOLST with the new directives. The NP stated if the resident had a DNR in place with a DNR code status identification band on, the staff should not have started CPR. 10NYCRR 415.3(e)(1)(ii)

Based on record review and interview conducted during the abbreviated survey (NY 617), it was determined for 1 of 9 residents (Resident #9) reviewed for quality of care, the facility did not provide services to the resident to attain or maintain the highest practicable physical and mental well-being. Specifically, - for Resident #9 who had an unresponsive episode and complained of and exhibited leg pain with bruising on the night shift from 8/29/2017 into the morning of 8/30/2017, registered nurse (RN) Supervisor #25 was not called timely, and when she was called, did not assess the resident. - Prior to being sent to the hospital on [DATE], there was no documented evidence Resident #9's pain was managed adequately. - The physician was not notified of the resident's unresponsive episode. This resulted in actual harm that was not immediate jeopardy for Resident #9 when she had significant pain that was not adequately managed for over 15 hours, through the time she was transferred to the hospital. Findings include: Resident #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 8/29/2017 licensed practical nurse (LPN) #17's progress note documented she was called to the resident's room by the certified nurse aide (CNA). The resident was lying in bed, warm to touch, and her eyes were rolling back in her head. The resident did not respond to her name. Vital signs were documented as blood pressure 117/43, respirations 15, pulse 91, oxygen saturation level (level of oxygen in the blood, normal 90-100%) was low at 80%, temperature 96.7 F (Fahrenheit), and blood sugar 183. The RN was called and oxygen was applied for comfort at 2 liters (L) per minute. The 8/29/2017 registered nurse (RN) Supervisor #11's progress note documented she was called by the LPN and told the resident does not seem like herself. The resident was able to state her name, was confused, and asked the nurse what she was doing. The resident's pupils were equal, grips were equal, and vital signs were within normal limits. The resident fell asleep during the assessment. The plan was to monitor. The 8/30/2017 at 1:41 AM, LPN #18's progress note documented she gave the resident 650 milligrams (mg) of Tylenol for complaints of leg pain at a pain level of 4. The 8/30/2017 at 3:04 AM, LPN #18's progress note documented the Tylenol was effective and the resident said the Tylenol helped a little but her leg still hurt and LPN #18 told her she could give her more Tylenol in 3 hours and re-position her. The 8/30/2017 at 5:42 AM, LPN #18's progress note documented the resident was given Tylenol, 650 mg for leg pain for a pain level of 5. LPN #18 documented on the 8/2017 Medication Administration Record (MAR) that the Tylenol given at 5:42 AM on 8/30/2017 was ineffective. The 8/30/2017 at 6:29 AM, LPN #18's progress note documented the resident complained of right leg pain that night and stated she was not able to move her legs although she was able to. The resident was medicated twice with Tylenol and was noted with bruises on her legs. The Supervisor was notified. The 8/30/2017 at 9 AM, respiratory therapist #21's progress note documented she found the resident on an oxygen concentrator without an order, took her oxygen saturation level on room air and it was 80%, documented oxygen saturation level on 2L oxygen was 90%, and she requested an oxygen order from the nurse practitioner (NP). The 8/30/2017 physician's orders [REDACTED].#19 at 11:43 AM, documented to obtain a chest x-ray, bilateral hip x-rays, bilateral leg x-rays, and labs. The 8/30/2017 at 1:24 PM, RN Manager #19's progress note documented she went to assess the resident who had an unresponsive episode the night before. The resident was alert and oriented, did not recall the event, and was on 3L of oxygen with oxygen saturation levels of 94%. The resident complained of hip and leg pain, there was no swelling of the extremities, and she received orders from the physician for labs and x-rays. The 8/30/2017 at 2:54 PM, LPN #20's progress note documented she gave the resident 650 mg Tylenol and it was ineffective. The 8/30/2017 at 3 PM, physician's orders [REDACTED]. The 8/30/2017 at 4:41 PM, physician's orders [REDACTED]. LPN #26 documented on the MAR the medication was not given as the resident was at the hospital. The 8/30/2017 4:43 PM, NP #4's progress note documented she evaluated the resident as she complained of right leg pain. The physician was called and ordered x-rays. NP #4 noted the resident's right leg was rotated outward and the x-ray showed an acute [MEDICAL CONDITION] femoral neck with displacement. She sent the resident to the hospital. The facility's 8/30/2017 investigation into the resident's right [MEDICAL CONDITION] included statements as follows: - LPN #17's statement documented she told the Supervisor that she applied oxygen to the resident for comfort and thought she had up to 24 hours to obtain an order for [REDACTED]. - RN Manager #11 documented she was called by the LPN who said the resident was not acting right. She did not realize the resident did not have an as needed oxygen order and she did not feel there was any reason to call the physician at that time. - CNA #23 documented on the 11 PM to 7 AM shift, the resident could not move at all. CNA #24 came to help her and the resident yelled that her leg was hurting. The resident was holding her leg and stated she could not move it. CNA #23 told LPN #22, who came in and asked the resident if she was okay to which the resident responded that her leg was hurting. CNA #23 documented on last rounds at 5 AM, she saw the bruises on the front of the resident's thighs that were blue/purple and LPN #22 was aware the resident continued to complain of leg pain. - LPN #22 documented she noticed the resident had bruising on both legs and complained of right leg pain on the night shift on 8/29/2017. - LPN #18 documented on 8/29/2017 on the night shift, LPN #22 told the RN Supervisor the resident had pain, she did not know if the RN Supervisor came to the unit to assess the resident, and she medicated the resident with Tylenol. On 10/24/2017 at 11:35 AM, LPN #17 stated in an interview, that in the evening of 8/29/2017, the CNAs came to her and said the resident was not acting right. She saw the resident who could not say what was wrong. She took her oxygen saturation level and it was low, she applied oxygen to the resident, and she called RN Supervisor #11 to assess the resident. On 10/20/2017 at 2:20 PM, RN Supervisor #11 stated in an interview, on 8/29/2017, she assessed the resident who was confused but she was told by LPN #17 that confusion was the resident's baseline. She stated she was not told that wearing oxygen was new for the resident, was not told that her eyes rolled back into her head before she came to the unit, and was not told she was unresponsive. She stated she saw the resident resting comfortably and did not think there was any reason to call the physician. She stated she left the facility at 11 PM and did not hear from the unit again about the resident. On 10/24/2017 at 1:35 PM, CNA #24 stated in an interview, on the night shift of 8/29/2017 into the morning of 8/30/2017, the resident was crying out in pain and did not sleep. He stated this was unusual for her as she normally slept well. He stated the first time he saw her was around 12 AM and she was moaning and groaning in pain and saying I hurt. He stated he told the nurse who did not normally work on that unit and also told CNA #23 (who was assigned to the resident). CNA #24 stated he did not feel that the nurse or CNA # 23 acted on what he reported so he tried to re-position the resident and she cried out in pain so he did not try again. He stated at some point, the nurse told him she gave the resident Tylenol. He stated he heard the resident moaning in pain on and off until 4 AM and then he left the area of her room to take care of other residents. He stated sometime between 2 AM and 4 AM, he told the nurse again that the resident was in pain. On 10/24/2017 at 3:40 PM, CNA #23 stated in an interview, on the night shift of 8/29/2017 into the morning of 8/30/2017, she took care of the resident. She stated on 8/30/2017 between 1 AM and 2 AM, she changed the resident with CNA #24 and she could not move her legs. She stated she told LPN #22 the resident was in pain and LPN #22 came to the room sometime between 3 AM and 5 AM. She stated the resident had bruises on the tops of her thighs but she was not sure if she noticed them or if LPN #22 noticed them and told her. On 10/24/2017 at 6:45 AM, LPN #22 stated in an interview, she thought it was around 5:20 AM to 5:30 AM on 8/30/2017 when she found out the resident had pain. She stated she looked at the resident's legs and saw bruising from the knee down. CNA #23 tried to turn her and the resident yelled out in pain. She stated she called RN Supervisor #25 and told her about the resident's leg pain and bruising and did not remember if she came to the unit. On 10/24/2017 at 7:07 AM, LPN #18 stated in an interview, she was on the resident's side of the unit on the night shift from 8/29/2017 into the morning of 8/30/2017. She stated during that shift, the resident had pain so she medicated her twice with Tylenol. She stated she was not a regular on the unit but she knew that pain was not usual for the resident. She stated she gave the resident Tylenol at the start of the shift and again at 6 AM. She stated the first time she went into the resident's room, she complained of pain and the CNA told her of the bruising on her legs. She stated the resident said she could not move her legs so she touched the bottom of her foot and her legs moved. She stated she looked at her legs and saw a combination of old and new looking bruises on her upper and lower legs. She stated at the end of the shift, she went into the resident's room again, gave her Tylenol, and the resident was still in pain so LPN #22 called RN Supervisor #25. On 10/24/2017 at 7:32 AM, RN Supervisor #25 stated in an interview, LPN #22 called her sometime between 6:30 AM and 6:45 AM and told her the resident woke up with leg pain. She stated she thought the resident slept through the night and it did not sound like an emergency so since it was close to the day shift, she figured the resident could be seen when the day RN came in. RN Supervisor #25 stated she could not remember if she was told about bruising but if she was told about bruising and pain she would have asked more questions. On 10/16/2017 at 10:45 AM, RN Manager #19 stated in an interview, on 8/30/2017, she came into work between 7 AM and 8 AM. She stated at around 10:30 AM to 11 AM, the staff told her the resident was in pain as they were trying to get her up and were having difficulty. She stated she told them to keep her in bed, she assessed her, and she called the physician for orders. She stated when she assessed the resident, they could not roll her because she was in so much pain, she tried to complete range of motion (ROM) but the resident jumped, and it was difficult to obtain her x-rays as she was in so much pain. She stated she did not look at the resident's upper legs or hips so she did not know if they were bruised. On 10/20/2017 NP #4 stated in an interview, when she examined the resident on 8/30/2017, the resident was weak and in a lot of pain. She stated she did not do ROM on her because her right leg was outwardly rotated. She stated she called the radiologist, discussed the x-ray results, and sent her to the hospital. She stated she did not recall what they were doing for the resident's pain from the time they initially called the physician in the morning until she saw her in the afternoon. She reviewed the MAR and stated [MEDICATION NAME] was ordered but the MAR documented it was not given as the resident was in the hospital at 4:41 PM. 10NYCRR 415.12

Based on record review and interview conducted during the abbreviated surveys (NY 930 and NY 388), it was determined for 5 of 8 residents reviewed for medications (Residents #1, 2, 3, 7 and 8), the facility did not ensure residents were free from significant medication errors. Specifically, - Resident #7's insulin was not administered as ordered and the resident was later found unresponsive with a low blood sugar. - The nurse did not administer ordered medications to Residents #1, 2, and 3 and she documented they were administered. - Resident #8 was not administered his medication for [MEDICAL CONDITION]'s disease as ordered. This resulted in actual harm for Resident #7 that was not immediate jeopardy. Findings include: The facility's Medication/Treatment Variance Report policy and procedure dated 2/12/2016 documented that medication variances can be due to many reasons including incorrect drug administration. The procedure documented when medication variances were reported a form would be initiated. The person who discovered the variance would ensure the variance was fully documented and the staff member(s) involved in the variance would be counseled or disciplined according to guidelines. The policy further documented the performance improvement goal was to prevent recurrence. 1) Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 8/2017 Medication Administration Record (MAR) documented an order initiated on 5/19/2017 for [MEDICATION NAME] (long-acting insulin), 50 units once a day for diabetes and to hold the [MEDICATION NAME] if the blood sugar was less than 120. On 8/3/2017 at 7:30 AM, the MAR documented that licensed practical nurse (LPN) #8 checked the resident's blood sugar, documented the blood sugar was 117, and documented that she administered 50 units of [MEDICATION NAME] to the resident. The 8/3/2017 emergency room (ER) report documented at 4:38 PM, the resident was sent to the hospital with unresponsiveness. The resident had a blood sugar of 54 and was given [MEDICATION NAME] at the nursing facility. In addition, the resident's oxygen saturation level (level of oxygen in the blood) dropped at the nursing facility, staff started bagging (artificially ventilating) her, her oxygen level improved, she became responsive, and then became unresponsive again. The resident's [DIAGNOSES REDACTED]. The resident was intubated (insertion of breathing tube) in the ER. In another section of the emergency room admission report, it documented the resident's blood sugar was 40 at the nursing facility prior to transfer. On 8/4/2017 at 1:24 PM, the Director of Nursing (DON) documented a late entry note for 8/3/2017 at 4:30 PM, specifying that she responded to the unit when the resident was unresponsive. The resident's blood pressure was 166/90, heart rate was 56, oxygen level was 89% on room air, blood sugar was 52, a non-rebreather was placed on the resident, and the ambulance was called. In an interview with LPN #8 on 10/17/2017 at 4:15 PM, she stated the resident was diabetic and on 8/3/2017, she would have checked her blood sugar in the morning. She reviewed the 8/2017 MAR and stated she documented the resident's blood sugar was 117 and she gave the resident 50 units of [MEDICATION NAME]. She stated she did not notice that the order documented to hold the [MEDICATION NAME] if the resident's blood sugar was below 120. In an interview with nurse practitioner (NP) #4 on 10/20/2017 at 10 AM, she stated when the resident was unresponsive, a code was called and she responded to the unit. She stated if the resident had returned to the facility after this incident, she would have reviewed her insulin regimen, blood sugars, and food intake to prevent future hypoglycemic episodes. She reviewed the resident's 8/2017 MAR and stated the [MEDICATION NAME] should have been held on 8/3/2017 as the blood sugar was documented as 117 and the order documented to hold the [MEDICATION NAME] if the resident's blood sugar level was less than 120. She stated [MEDICATION NAME] was long-acting insulin and it could have had an effect on the resident's blood sugar being low and on her having the unresponsive episode. In an interview with the DON on 10/20/2017 at 11:15 AM, she stated she was not aware LPN #8 did not follow the resident's insulin order on 8/3/2017 and was not aware she administered [MEDICATION NAME] when the blood sugar was less than 120. She stated the insulin should have been administered as ordered. 2) Resident # 8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 6/2017 Medication Administration Record (MAR) documented the resident had an order for [REDACTED]. The MAR included documentation from multiple nurses that the medication was administered as ordered throughout the month of 6/2017. On 9/21/2017 at 9:45 AM, registered nurse (RN) Manager #1 stated in an interview, he heard about an issue with the resident's [MEDICATION NAME] in 6/2017 and was told the resident's spouse asked the nurses to count the medication as it was time for the medication to be re-ordered and when the resident's spouse told the nurse, she said the resident had many pills left. He stated he did not investigate the issue. On 9/21/2017 at 12:05 PM, the Quality Assurance (QA) RN #3 stated in an interview, she was not able to locate any documentation about medication errors involving the resident. On 9/21/2017 at 1 PM, licensed practical nurse (LPN) #5 stated in an interview, she spoke with the resident's spouse in 6/2017 because the resident had many [MEDICATION NAME] pills left and did not need them to be re-ordered as scheduled. On 9/22/2017 at 12:15 PM, the resident's spouse stated in an interview, on either 6/2 or 6/3/2017, she brought 60 pills to the facility and at the end of the month she was told the resident had 51 pills left and none were needed at that time. She stated she told RN Manager #2 and nurse practitioner (NP) #4. On 10/2/2017, the Administrator's Administrative Assistant documented in an email, the facility did not have any medication error reports for the resident and if any were found, they would be forwarded to the surveyor. On 10/16/2017 at 10:10 AM, RN Manager #2 stated in an interview, she remembered there was a time when the resident's spouse went to bring in more medications for him and the facility did not need any more as he had many pills left. She stated LPN #5 notified her of this and she called the resident's spouse to tell her they were going to look into it. NP #4 stated in an interview on 10/20/2017 at 10 AM, that she was aware there was an issue with the resident's medication not being administered over the summer and she was told of the issue by the resident's spouse. She stated one day, she saw the resident and his [MEDICAL CONDITION]'s symptoms looked a lot better, his movements had decreased and his mood was better. She stated she told this to the resident's spouse and the resident's spouse told her it was because he was receiving his medications again. NP #4 stated the resident's spouse then told her that the resident had not been getting his medication for [MEDICAL CONDITION]'s disease in 6/2017 and at that time, he was receiving it again. NP #4 stated by the time she found out about the issue it was after the fact. 3) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the 5/29/2017 Minimum Data Set (MDS) assessment the resident's cognition was moderately impaired. The 8/2017 Medication Administration Record (MAR) documented licensed practical nurse (LPN) #8 signed that she administered the resident the following medications on 8/4/2017 at 10 AM: - Aspercreme [MEDICATION NAME] (pain patch), omperazole ([MEDICATION NAME], stomach medication), Apixaban (blood thinner), [MEDICATION NAME] sulfate (iron), [MEDICATION NAME] (to treat chest pain), and [MEDICATION NAME] (breathing medication). The 8/4/2017 Medication/Treatment Variance and Omission Report documented LPN #8 committed a medication error on the resident with the medications listed above (Aspercreme [MEDICATION NAME], omperazole, Apixaban, [MEDICATION NAME] sulfate, [MEDICATION NAME], and [MEDICATION NAME]). On 9/8/2017 at 1:10 PM, registered nurse (RN) Manager #9 stated in an interview, on 8/4/2017 when LPN #8 left the facility, LPN #10 took over for her and when LPN #10 was done with the medication pass she noticed medications for 3 residents (including this resident) in the medication cart that had not been given and were signed as given. On 9/8/2017 at 1:56 PM, LPN #10 stated in an interview, on 8/4/2017 she took over for LPN #8 after 11 AM and found medications in the medication cart for 3 residents that were due to be given in the morning. The medications were not given and were signed as given. She stated Resident #3 was alert and oriented and told her he had not received his medications that morning so she gave them to him. She stated she did not recall how she documented that she gave those medications and that they were not given by LPN #8 or what time she gave the medications. On 10/17/2017 at 4:15 PM, LPN #8 stated in an interview, she remembered the day she was sent home early and knew another nurse took over for her. She stated she did not remember signing for 3 residents' medications that she did not give but said it was possible she did not get to administer them prior to 11 AM when she left the facility. 10NYCRR 415.12(m)(2)

Based on record review, observation, and interview conducted during the abbreviated Survey (NY 627), it was determined the facility did not ensure 1 of 3 residents (Resident #1), reviewed for advance directives, had their advanced directives honored. Specifically, Resident #1 was resuscitated despite a Do Not Resuscitate (DNR) order included in the resident's medical record. This resulted in actual harm that is not immediate jeopardy. Findings include: The facility Advanced Directives policy dated ,[DATE] and provided to the surveyor on [DATE] at 11:25 AM, documented it was the policy of the facility to ensure resident/patients advanced directives be honored. An unsigned Code Blue Management policy was reviewed on [DATE] and documented that if a resident experiences [MEDICAL CONDITION], the facility will provide basic life support, including CPR in an accordance with the residents advanced directives until emergency services arrive. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired and she required supervision with activities of daily living (ADL's). The Medical Orders for Life Sustaining Treatment (MOLST) form dated [DATE] documented the resident did not want to be resuscitated, did not want to be intubated, wanted limited medical interventions, and wished to be sent to the hospital only if necessary. The comprehensive care plan (CCP) and resident care guide (care instructions) dated [DATE] did not document the residents code status or advanced directives including any MOLST form directives. The physician's orders [REDACTED]. The registered nurse (RN) progress note dated [DATE] at 11:22 AM documented: - licensed practical nurse (LPN) #1 provided the resident with her medication at which time the resident became unresponsive and no pulse or respirations were identified; - CPR was initiated by LPN#1: - RN #3 arrived on the unit, placed an artificial airway; - CPR continued for 1 minute at which time the resident responded; - LPN #2 stated the resident was a full code; and - after CPR was completed, RN #5 identified on the residents computerized chart the resident has a physician ordered DNR. The facility investigation report dated [DATE] documented: - Resident #1 was witnessed unresponsive; - LPN #1 called for help; - LPN #2 approached the residents room, checked for pulse and respiration, and an All Come Code was called. - RN # 3, 4 and 5 responded and when they arrived on the unit were informed by LPN #2 the resident had a full code status. During interviews conducted on [DATE] and [DATE], it was identified that 3 RNs and 2 LPNs responding to the code on [DATE] did not check Resident #1's MOLST form before initiating or participating in the resident's CPR. During interviews on [DATE] and [DATE], 2 of 12 licensed nursing staff did not know to check the MOLST form to identify the code status of a resident. Resident #1 was observed on [DATE] at 11:07 AM in her wheel chair participating in a computerized activity. She stated she thought she had gone to the hospital recently, however was unable to recall the incident. When interviewed on [DATE] at 11:25 AM LPN #2 stated she received her CPR certification from outside of the facility and she received facility training to identify a residents' code status on the computer. LPN #2 stated on the date of the incident she heard LPN #1 call for help,entered the resident's room, checked for pulse and respirations and the resident did not have any. LPN #2 stated she left to get the crash cart, called a come to code for the supervisor and returned to the resident's room where RN #3 directed RN #5 to call 911. LPN #2 said RN #3 then asked the resident's code status. LPN #2 stated she thought the resident was a full code. She stated RN #5 went to the computer while on the phone with 911 and pulled up the resident's information and determined the resident was a DNR. She stated the RN Supervisors took over and she left. When interviewed on [DATE] at 2:55 PM, RN #7 stated she provided CPR training for the facility and some staff obtain their certification from an outside source. She stated all licensed staff were required to have CPR certification and if requested, CNA's were included in the class. She stated staff received education on identifying a resident's code status when trained for CPR. She stated a resident's code status was identified by looking at the MOLST on the unit and by looking in the computer. She stated that, additionally, residents with a white bracelet with black background and white print indicated a full code and a resident with a white bracelet with white background and red print indicated DNR. She stated that, additionally, a red dot located at the head of the bed indicates DNR. When asked for documentation of training provided on this information or an attendance list for this training she was unable to provide this surveyor with any documentation. She stated she provided the education to staff that received CPR training in the facility. When interviewed on [DATE] at 1:37 PM RN #3 stated the facility training identified DNR residents as those that wore white and black bracelets and CPR residents did not have anything. RN #3 stated if the resident did not have a bracelet she would look at the MOLST form. She stated if she was unable to identify the residents' code status she would initiate CPR. She stated residents also had a little sticker the size of a quarter on the head of the bed to indicate DNR. RN #3 stated she did not know the policy regarding code status as she had not looked at it. She stated on [DATE] she heard a come to code, arrived on the unit, met LPN #2 in the hall and LPN #2 stated Resident #1 was a full code. She stated when she arrived in the room LPN #1 was doing chest compressions without a back board and she did not believe the compressions were effective without the board. RN #3 stated she obtained an airway and RN #5 went to look at the medical record. She stated the resident's pulse returned and the resident had become responsive when RN #5 returned to the room and told them she was a DNR. RN #3 stated she did not look for facility indicators including the MOLST prior to initiating CPR and she took the LPN's word for it. When interviewed on [DATE] at 11:20 AM, RN #5 stated she did not recall if she received facility training on a resident's code status. She stated when the incident occurred and she responded to the code, LPN #1 was doing chest compressions. RN #5 said she followed RN #3 out into the hall way to obtain an airway. RN #5 stated she went to the computer to obtain the resident's medical records for transport and identified the resident's code status was a DNR while calling 911. RN #5 stated she then went to the resident's room and told RN #3 the resident was a DNR and at that time the resident had a pulse and CPR had stopped. When interviewed on [DATE] at 11:05 AM, the Medical Director stated she identified the resident code status by the computerized medical record, a red dot on the resident headboard, and the resident's bracelet. She stated since the incident occurred she thought some education had occurred. She stated there was a MOLST book on the units however when a resident was unresponsive the staff should check the computer rather than hunting down the MOLST and then check the wrist band. She stated all identifiers should be in synch. She stated she reviewed the polices for the facility and was unable to recall if the facility had a policy on identifying a resident code status. When interviewed on [DATE] at 11:55 AM, LPN #1 stated she had not received any training on CPR or on identifying the residents code status prior to the incident. LPN #1 stated she was unable to locate a policy prior to the incident. She stated on [DATE] when Resident #1 became unresponsive, she yelled for help, LPN #2 responded, and they both checked for pulse and respirations. She stated LPN #2 reported to her that Resident #1 was a full code. She stated she began CPR and LPN #2 went to call a code blue. She stated she did not have a back board and when LPN #2 went to retrieve one she heard her tell the RNs the resident was a full code. She stated all 3 RNs entered the room as she provided CPR. She said RN #3 assisted her with obtaining an airway and RN #5 went to call 911. LPN #1 stated, while RN #4 was setting up the AED, she had stopped to cut the residents clothing and reinitiated CPR. She stated RN #5 returned to the room and announced Resident #1 was a DNR at that time, the resident began to arouse, and we continued to monitor her until the ambulance arrived. She stated she received a call from the facility inquiring about the incident the following day and was asked if she checked the residents' bracelet or the red dot on the bed that indicated the code status and she stated she was not aware of any of the indicators. She stated she was not aware to check the MOLST prior to initiating the CPR. When re-interviewed on [DATE] at 11:34 AM, RN #3 stated she did not check the Resident #1's identification band or MOLST form prior to participating CPR. She stated she took direction from LPN #2 when she stated the resident was a full code. She stated she did not know the policy of the facility when determining the residents code status and assumed it was her responsibility to check the residents code status before initiating CPR. 10NYCRR 415.3(e)(1)(ii)

Based on record review, interview, and observation conducted during the abbreviated surveys (NY 801 and NY 374), it was determined for 2 of 3 residents reviewed for accidents (Residents #4 and 5), the facility did not provide adequate supervision and assistance devices to prevent accidents. Specifically, - For Resident #5, who was locked out of the facility by a staff member, the resident was not provided with adequate supervision when he was left outside alone; when the assigned care givers did not account for his whereabouts for an entire shift, and the resident was not provided with a safe plan for re-entering the facility. This resulted in actual harm for Resident #5 as he sustained a head laceration requiring 6 sutures. - For Resident #4, who was a new admission, the facility did not ensure adequate supervision was provided when the resident was wandering and actively exit-seeking. 1) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was cognitively intact per the 4/17/2017 Minimum Data Set (MDS) assessment. The 6/1/2017 ambulance report documented the resident was picked up at 9:31 PM, in front of a public building on the opposite side of the street as the nursing facility. The resident hit his head on the sidewalk and had a laceration that required suturing. The resident told the EMTs he was locked out of the facility; banged on the door and could not get in, and then fell when he crossed the street. The 6/1/2017 emergency room progress note documented the resident presented with a 2.5 centimeter (cm) laceration above the left eye, 1 cm abrasion to the forehead, and a bruise to the left thigh with complaints of tenderness. Sutures were applied to the laceration. The 6/2/2017 incident report initiated at 1:43 AM, documented the resident was last seen on the unit at around 6 PM and was known to wander the facility. At 11:45 PM, staff called the Supervisor and a code yellow (missing person) and law enforcement were called. Local law enforcement informed the facility the resident was taken to the hospital. Statements attached to the incident report included: - The resident's statement documented he went out the front door to wait for his family member and was told the doors were locked at 8:30 PM. He did not want to come inside so the staff person told him to use the side door. The side door was locked so he walked down the street, his walker caught the curb, and he fell . He stated a passerby called an ambulance. - Certified nurse aide (CNA) #17's statement documented the resident was not in room at 8 PM and was not there later in the shift either. She asked other staff members if they knew where he was and was told he liked to walk around the building. - Licensed practical nurse (LPN) #18's statement documented the resident was not in his room at 8 PM when he went to give him medications and it was normal for him to be off the unit. At 10:45 PM, a CNA asked him where the resident was and when they could not find him, he called the Supervisor. - Receptionist #19's statement documented at 8:20 PM, the resident was outside and she told him the doors were locked at 8:30 PM. At 8:30 PM, the resident did not want to come in, and he was told to use the side doors when he was ready to come inside. - Maintenance Staff #20's statement documented when he went to lock the doors at 8:30 PM, the resident was sitting outside and did not want to come in. He told the resident use the side door when he was ready to come inside and he locked the front doors. The 6/2/2017 nurse practitioner (NP) #15's progress note documented the resident was seen following a fall and return from the emergency room . The note further documented details surrounding the fall were uncertain at the time of the note and what she did know was that the resident was found to be missing from the facility at 1:00 AM on 6/2/2017 and was found at a local hospital. The resident sustained [REDACTED]. On 7/3/2017 at 10:29 AM, Receptionist #19 stated in an interview, at 8:30 PM, the front doors to the facility were locked and if someone wanted to get into the building after 8:30 PM, they needed to go to the side door, pick up the phone, and call the 1S Unit. She stated on 6/1/2017, the resident was told to use the side door when he wanted to come in as he did not want to come in at 8:30 PM. She stated she did not think anything of it as the resident often sat outside and seemed reliable. She stated she left shortly after 8:30 PM and did not let anyone know the resident was outside when she left. On 7/3/2017 at 11:40 AM, the resident stated in an interview, the night he fell , he was sitting outside and the staff told him they were locking the doors. He said he was told to go to the side door when he wanted to come in but when he did, the doors were locked. He stated he banged on the door and when no one came, he left. He stated he fell and hit his head on the curb and someone called an ambulance. On 7/5/2017 at 4:11 PM, Maintenance Staff #20 stated in an interview, on 6/1/2017, he went to lock the doors at 8:30 PM and the resident said he was not ready to come inside. He stated he told the resident to use the side door when he was ready to come in and he thought the resident knew how to pick up the phone and call the 1S Unit. He stated he did not tell anyone the resident was outside after he locked the doors at 8:30 PM. On 7/6/2017 at 2:22 PM, CNA #17 stated in an interview, when she started her shift at 3 PM on 6/1/2017, the resident was in his room. She stated when she went to pick up dinner trays she noticed his meal was in his room untouched. She was told by other CNAs who were regulars on the unit to leave the meal as he would come back and eat it later. She stated between 8 and 9 PM, she passed linens and the resident was not back so she asked other CNAs again and they told her he walked around the building. She did not report her concerns to a nurse as the LPN was a float. CNA #17 stated when she left that night, he had not returned. On 7/6/2017 at 2:35 PM, LPN #18 stated in an interview, the resident was not in his room at 8 PM when he had a medication due but he did not think much of it as it was the norm for the resident to be off the unit for an entire shift visiting a resident on another unit. He stated after the 8 PM medication pass, he did his work and at 11 PM a CNA asked him where the resident was. He stated that at that time, they started looking for the resident. On 7/7/2017 at 12:30 PM, the Director of Nursing (DON) stated in an interview, the resident's cognition was okay but he had poor judgement. She stated the facility's front door was locked at 8:30 PM and the resident should not have been locked out. She stated if he refused to come inside, the staff should have called the Supervisor for assistance. She stated no residents should be using the facility's side doors as you had to walk through the parking lot to get there and it was not a safe area. She stated the CNAs and LPN on the unit also should have known the resident's whereabouts on their shift. She stated even though he walked around the building, they should be verifying his whereabouts during their shift. On 7/13/2017 at 10 AM, NP #15 stated in an interview, she saw the resident on 6/2/2017 when he returned from the hospital and he had sutures to the laceration above his eyebrow at that time. She stated she had been working with the facility's team and the resident on improving his accountability for his whereabouts and did hear that he was locked out of the building the night that he fell . 2) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's palliative care consultation (completed in the hospital) dated 6/7/2017 documented the resident could not explain why he was in the hospital and did not know what year it was. The hospital discharge summary, dated 6/13/2017, documented the resident's [DIAGNOSES REDACTED]. The initial elopement risk assessment completed on 6/14/2017 at 4:51 PM, by registered nurse (RN) #8 documented the resident's risk factors for elopement included: disorientation; lack of understanding of his surroundings; newly admitted , and ambulating with one assist. The assessment did not identify the resident as having dementia and did not document he took an antidepressant. The resident scored at low risk for wandering/elopement based on this assessment. The initial nursing assessment dated [DATE] at 4:53 PM and completed by RN #8 documented the resident did not know why he was at the facility, was confused, and was oriented to person and not to place or time. The incident report dated 6/14/2017 documented the resident was admitted to the facility at 4:40 PM and was noted to be missing at 6 PM. A code yellow was called and local law enforcement returned the resident to the facility. The investigation summary documented the resident was assessed for wandering risk, was a new admission, and was assessed to be at low risk for wandering at admission. The 6/14/2017 physician's orders [REDACTED]. After the resident was returned to the facility, RN #8 completed a second elopement risk assessment dated [DATE] at 7:22 PM. The assessment documented the resident's risk factors for elopement included: disorientation; lack of understanding of his surroundings; newly admitted ; experiencing a change in staff/caregiver; independent with ambulation; a [DIAGNOSES REDACTED]. The use of an antidepressant medication was not checked. The resident scored at high risk for elopement on this assessment. The 6/15/2017 social worker's progress note documented the resident had severely impaired cognition. On 6/28/2017 at 1:15 PM, RN #8 stated in an interview, when the resident was admitted he completed the initial nursing assessment and elopement risk assessment by examining the resident and reviewing the information from the hospital. He stated when he was done, he left the unit to call the physician and obtain the admission orders [REDACTED]. On 7/3/2017 at 4 PM, certified nurse aide (CNA) #10 stated in an interview, after the resident was admitted to the facility, he was wandering the unit, walking in and out of other residents' rooms, trying to leave, was confused, and they tried to keep an eye on him. She stated at around 5:30 PM, the resident was sitting near the nurse's station, the staff left the area to pass meal trays, and the resident left the unit at that time. On 7/3/2017 at 4:10 PM, CNA #11 stated in an interview, after the resident was admitted , he was wandering the unit asking where he was. She stated the staff re-directed him but when they were busy passing meal trays, he left the unit. On 7/5/2017 at 2:05 PM, licensed practical nurse (LPN) #12 stated in an interview, after the resident was admitted , they tried to get him to sit at the tables near the nurse's station so they could watch him because he was wandering the unit. She stated another nurse (LPN #13) stopped by the facility and even though she was not on duty, she stayed with the resident because herself and the other LPN on duty (LPN #14) were busy. She stated the resident kept saying that his car was at the facility and he needed to get to his car and go home. She stated when LPN #13 left, the CNAs were busy passing dinner trays, she was administering insulin, and LPN #14 was administering a tube feeding, and that was when the resident left the unit. She stated LPN #14 was the resident's assigned nurse and she thought LPN #14 called the Supervisor and asked for a wanderguard and was told they did not have any available. LPN #12 stated when the resident was returned to the unit, he said he checked every car in the parking lot for his car and when he did not find his car, he started walking home. On 7/5/2017 at 3:30 PM, LPN #14 stated in an interview, after the resident was admitted , he was wandering the unit, going in and out of other residents' rooms, and asked for the way out as he said his car was in the parking lot and he needed to get to his car and leave. She stated it was difficult to keep track of the resident and because he asked her to show him the way out, she called the Supervisor and asked for a wanderguard. She stated the Supervisor stated they would bring one but they did not receive it prior to him being found to be missing. On 7/6/2017 at 10:30 AM, QA RN #7 stated in an interview, she completed the investigation into the resident's elopement and considered the elopement risk assessment. She stated she questioned whether the resident's medications were checked if that would have made him high risk for elopement but she did not look into why the RN did not check that the resident had a dementia [DIAGNOSES REDACTED]. In a follow-up interview with RN #8 on 7/6/2017 at 1:55 PM, he stated when he assessed the resident, the resident was lying in bed and was not wandering the unit. He stated when he left the unit, he told the staff he was going to call the physician to obtain admission orders [REDACTED]. He stated the unit staff did not call him to ask for a wanderguard prior to the resident's elopement and he was not notified the resident was wandering or that they were having difficulty keeping track of him. He stated the resident was found a few streets away, he did not know the exact location, and when the resident returned, he mentioned he was looking for his car. On 7/10/2017 at 12:30 PM, the DON stated in an interview, that at the end of 7/2017, the VP of Clinical Services planned to provide education to the nurses on the admission process including admission assessments. She stated she was not aware RN #8 did not check that the resident had dementia on the initial elopement risk assessment and stated she would not have expected him to check the medications as risk factors until he was aware whether the physician was going to continue the hospital medication orders. She stated she was not told that LPN #13 was watching the resident when she was not on duty and was not aware the staff on the unit were having difficulty keeping an eye on the resident prior to his elopement. She stated there were many RNs in the building at that time, and the unit staff should have called for help if they needed it. The surveyor attempted to contact LPN #13 via the telephone and no response was received. 10NYCRR 415.12(h)(1&2)

Based on record review, observation, and interview conducted during the recertification and abbreviated surveys (NY 828 and NY 485), it was determined the facility did not ensure residents were provided with the necessary services to maintain optimal physical well-being for 7 of 30 residents (Residents #1, 13, 14, 16, 17, 24, and 25) reviewed for quality of care. Specifically: - Resident #16 experienced harm when she exhibited signs of severe pain and was not assessed timely, and when x-ray results showed a femur fracture and were not addressed timely. Additionally, the resident was not medicated adequately for pain after the fracture was identified. - Resident #1 was found with an open skin area and she was not assessed timely. - Resident #13 had elevated fingerstick blood sugar levels and the physician was not consistently notified. - Resident #14 had sutures without documented evidence the suture site was observed or monitored timely. - Resident #17 had staples placed in her head following a fall and there was no documented evidence the wound and staples were monitored, when the staples were removed, or who removed the staples. - Resident #24 had sutures for a leg laceration, and there was no documented evidence the wound was monitored timely and it became infected. When the resident was prescribed antibiotics for 10 days for the infection, the antibiotic was administered for only 9 days. - Resident #25 had an order for [REDACTED]. This resulted in actual harm that is not immediate jeopardy for Resident #16. Findings include: 1) Resident #16 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. She needed extensive assistance for all activities of daily living (ADL), and did not exhibit symptoms of pain. UNTIMELY ASSESSMENT Licensed practical nurse (LPN) #9's progress note dated 9/9/2016 at 9:59 PM documented during evening care, the resident screamed, hollered, and cried when her left hip area was touched. LPN #9 documented she medicated the resident with Tylenol 650 milligrams (mg). The resident screamed and hollered in pain when she tried to perform range of motion (ROM) to her left leg, and she notified registered nurse (RN) Supervisor #12. There was no documented evidence the resident was assessed by the RN or other qualified person. The 24-hour nursing report dated 9/9/2016 for the day shift documented the resident was noted to scream and holler/cry in pain when left hip area is touched and Tylenol was given per RN Supervisor #12. The report contained no additional documentation for the resident. The nurse practitioner (NP) #10's progress note dated 9/10/2016 at 11:41 AM documented she was asked to evaluate the resident for knee and hip pain, as the staff reported the resident was grimacing and crying out in pain last night with movement of the left leg. The resident grimaced immediately with palpation of the leg, NP #10 could not perform passive ROM, and the left knee was [MEDICAL CONDITION] (swollen). NP #10 ordered an x-ray of the left knee, hip, and ankle. LPN #13's progress note dated 9/10/2016 at 2:31 PM documented the resident was grimacing and crying when moving her leg and an x-ray was ordered. The x-ray report documented the x-ray was obtained on 9/10/2016 at 3:01 PM, and the results were available at 3:56 PM and documented the resident sustained [REDACTED]. NP #10's progress note dated 9/11/2016 at 2:35 PM documented she was aware of the resident's fracture and was sending her to the hospital. RN #11's progress note dated 9/11/2016 at 3:05 PM documented the resident was sent to the hospital per the NP's order. RN #12's progress note dated 9/11/2016 at 9:25 PM documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. An accident and incident report dated 9/11/2016 documented: - On 9/9/2016 at 8:59 PM, LPN #9 reported during evening care, resident screams with pain upon touch in left hip area. - An attached statement by certified nurse aide (CNA) #15 documented that on 9/9/2016 during second rounds, the resident screamed when she turned her from one side to the other, and she could not touch the resident any more. CNA #15 documented she told LPN #9 and she finished care as slowly as she could. - An attached statement from LPN #9 documented at 7:30 PM on 9/9/2016, CNA #15 told her that the resident was screaming in pain when touched on her left side so LPN #9 went into the room and the resident also screamed when she touched her left side. LPN #9 documented she called RN Supervisor #12, who told her someone would assess the resident. LPN #9 gave her Tylenol, and when she left at 9:30 PM, no one had assessed the resident. LPN #9 documented when she left, LPN #19 took over for her. - An attached statement from CNA #14 documented on 9/10/2016 when she touched the resident's left leg, she cried out. CNA #14 documented she told the nurse and finished the resident's care. CNA #14 documented the resident was fine during the day, but when she tried to provide care again, the resident cried out during transferring, taking off shoes, socks, and pants, then even rolling her side to side to do peri-care and change brief. She documented she told the nurse again, who said several people had been notified and imaging was pending. CNA #14 documented she told the nurse she documented the resident had behaviors of crying and yelling out and was in pain. The resident's comprehensive care plan (CCP) was updated 9/12/2016, documenting she had a fracture. The plan included monitoring pain and medicating per physician's orders [REDACTED]. During an interview on 1/20/2017 at 2:41 PM, CNA #14 stated when she tried to provide care on 9/10/2016, the resident was screaming and had tears in her eyes and she did not want to touch her. She stated she told the LPN and continued to dress the resident as gently as she could. The LPN told her she called the Supervisor and the resident had to be up out of bed for meals because she was on aspiration (swallowing) precautions. She stated she sat the resident on the side of the bed and she was okay, but when she lifted her she could see the pain in her face. She stated once in the chair she was okay, but when she put her back to bed, the resident screamed and she could again see the pain in her face. During an interview on 1/20/2017 at 10:31 AM, LPN #19 stated that when LPN #9 left on 9/9/2016 at 9:30 PM, he would have taken the keys from LPN #9 and would have been covering 2 units. He stated LPN #9 gave him report on other residents, but did not report anything on this resident. LPN #19 stated he did not remember checking the resident specifically, but it was his usual practice to check every resident when he worked even when he covered 2 units. He stated if the resident was asleep, he would not have disturbed her. He stated when he left work at 11:00 PM on 9/9/2016, he was not aware the resident had complaints of pain. On 1/20/2017 at 11:20 AM, LPN #9 stated in an interview: - On 9/9/2016, between 8 and 10 PM, the CNA told her resident was screaming in pain so she went into room and rolled resident over and the resident also screamed and hollered. LPN #9 touched her left side and she screamed. She stated this was unusual for the resident, as she never screamed and rarely spoke. - After she left the room, she called RN Supervisor #12, wrote a progress note, and documented it on the 24-hour nursing report. - When she left at 9:30 PM, LPN #19 took her keys, she gave him verbal report, and the resident was also documented on the written report. - She stated the next day, 9/10/2016, she worked on another unit and asked NP #10 about it. NP #10 was not aware and said she would assess the resident. During an interview on 1/20/2017 at 11:12 AM, RN #12 stated she was called to assess the resident on 9/9/2016 at around 10:30 PM or 11:00 PM. She stated she did not get to it, did not document about it, and asked the oncoming Supervisor, RN #18, to do the assessment. During an interview on 1/20/2017 at 11:20 AM, RN #18 stated she did not remember being asked to assess the resident on 9/9/2016. She stated if she were aware the resident had pain, she would have assessed her and made sure the staff were medicating her for pain. During an interview on 1/20/2017 at 11:52 AM, NP #10 stated the resident normally was not in pain, but she had lots of pain on 9/9/2016. She stated she was first aware on 9/10/2016 when LPN #9 told her and asked her to assess the resident. She stated she ordered an x-ray and then sent the resident to the hospital when she knew she had a fracture. She stated the Supervisor received the x-ray results and notified her. She stated the x-ray results came to a fax machine on the first floor. NP #10 did not know if a specific person was responsible for checking the fax machine, and she did not know how often they checked the fax machine. She stated it could be the next day between an x-ray being received at the facility, and it being given to medical to address. During an interview on 1/20/2017 at 12:47 PM, the DON stated the RNs in the building were responsible for checking the fax machine on the first floor for x-ray results. She stated there was no set time to do this, but it should be done throughout the shifts. PAIN MANAGEMENT Licensed practical nurse (LPN) #9's progress note dated 9/9/2016 at 9:59 PM documented during evening care, the resident screamed, hollered, and cried when her left hip area was touched. LPN #9 documented she medicated the resident with Tylenol 650 milligrams (mg). The resident screamed and hollered in pain when she tried to perform range of motion (ROM) to her left leg, and she notified registered nurse (RN) Supervisor #12. The 9/2016 Medication Administration Record [REDACTED] - The resident was administered Tylenol 650 mg on 9/9/2016 at 9:45 PM. - The resident had an order for [REDACTED]. The nurse practitioner (NP) #10's progress note dated 9/10/2016 at 11:41 AM documented she was asked to evaluate the resident for knee and hip pain, as the staff reported the resident was grimacing and crying out in pain last night with movement of the left leg. The resident grimaced immediately with palpation of the leg, NP #10 could not perform passive ROM, and the left knee was [MEDICAL CONDITION] (swollen). LPN #13's progress note dated 9/10/2016 at 2:31 PM documented the resident was grimacing and crying when moving her leg and an x-ray was ordered. There was no documented evidence the resident was medicated for pain after receiving Tylenol that morning at 8:00 AM. The x-ray report documented the x-ray was obtained on 9/10/2016 at 3:01 PM, and the results were available at 3:56 PM and documented the resident sustained [REDACTED]. RN #11's progress note dated 9/11/2016 at 3:05 PM documented the resident was sent to the hospital per the NP's order. RN #12's progress note dated 9/11/2016 at 9:25 PM documented the resident returned from the hospital with a [DIAGNOSES REDACTED]. The 9/2016 Treatment Administration Record (TAR) documented on 9/11/2016, on the evening shift the resident had pain at a level of 6 out of 10 (on the 0-10 scale. The 9/2016 MAR indicated [REDACTED]. The 9/2016 MAR indicated [REDACTED]. The resident's comprehensive care plan (CCP) was updated 9/12/2016, documenting she had a fracture. The plan included monitoring pain and medicating per physician's orders [REDACTED]. The Director of Nursing's (DON) progress note dated 9/15/2016 at 10:42 AM documented the resident's leg was tender to the touch and warm, and she asked the NP to evaluate pain control and warmth. NP #10's progress note dated 9/15/2016 at 10:57 AM documented staff reported very little pain control. [MEDICATION NAME] was ordered every 6 hours as needed and was not being administered, as staff may not have been assessing pain correctly as the resident was not able to advocate for herself. The resident moaned in pain with very little palpation to the left knee, and the NP changed the resident's [MEDICATION NAME] to every 8 hours for better pain control. The 9/2016 MAR indicated [REDACTED]. During an interview on 1/20/2017 at 2:41 PM, CNA #14 stated when she tried to provide care on 9/10/2016, the resident was screaming and had tears in her eyes and she did not want to touch her. She stated she told the LPN and continued to dress the resident as gently as she could. The LPN told her she called the Supervisor and the resident had to be up out of bed for meals because she was on aspiration (swallowing) precautions. She stated she sat the resident on the side of the bed and she was okay, but when she lifted her she could see the pain in her face. She stated once in the chair she was okay, but when she put her back to bed, the resident screamed and she could again see the pain in her face. During an interview on 1/20/2017 at 11:20 AM, RN #18 stated she did not remember being asked to assess the resident on 9/9/2016. She stated if she were aware the resident had pain, she would have assessed her and made sure the staff were medicating her for pain. On 1/20/2017 at 11:20 AM, LPN #9 stated in an interview: - On 9/9/2016, between 8 and 10 PM, the CNA told her resident was screaming in pain so she went into room and rolled resident over and the resident also screamed and hollered. LPN #9 touched her left side and she screamed. She stated this was unusual for the resident, as she never screamed and rarely spoke. - The resident returned from the hospital with an order for [REDACTED]. - She stated the resident could not rate her pain on a pain scale, and on those days when she gave her as needed [MEDICATION NAME], the resident was moaning and grimacing. During an interview on 1/20/2017 at 11:52 AM, NP #10 stated the resident normally was not in pain, but she had lots of pain on 9/9/2016. She stated she was first aware on 9/10/2016 when LPN #9 told her and asked her to assess the resident. She stated she ordered an x-ray and then sent the resident to the hospital when she knew she had a fracture. She stated she initially ordered as needed [MEDICATION NAME] and then changed it to routine, as she saw the resident was rarely being given the [MEDICATION NAME]. She thought that was because the staff were not assessing the resident's pain correctly due to her severe dementia. She stated the staff should have been looking at the resident for signs of pain such as grimacing with movement, and then medicated her with as needed [MEDICATION NAME]. 2) Resident #24 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and required extensive assistance with activities of daily living (ADLs). The comprehensive care plan (CCP) dated 12/27/2016 documented the resident had an ADL deficit related to dementia and limited mobility. Interventions included a wheelchair for self-propelling, and extensive assistance of 1 for transfers utilizing a rolling walker. The registered nurse (RN) progress note dated 12/31/2016 at 4:39 PM documented the resident was found sitting in her wheelchair with her left leg bleeding. The bleeding was controlled with pressure. The physician order [REDACTED]. The hospital report dated 12/31/2016 documented the resident had 6 sutures placed in the larger 8 centimeters (cm) x 5 cm laceration, and Steri-Strips placed on the smaller 3 cm x 3 cm laceration. The discharge instructions documented to: keep cut clean and dry, clean with soap and water 2 times daily, change dressing and apply medicated cream as instructed by your doctor, and remove stitches in 8 to 10 days. The next nursing progress note dated 1/1/2017 at 5:45 AM documented the resident had no known changes, no complaints, and slept through the night. There was no documented evidence the resident was assessed after returning from the hospital and no evidence the physician was notified to determine if a treatment or monitoring of the resident's sutures was needed. The resident's nursing notes documented: - A licensed practical nurse (LPN) note dated 1/2/2017 at 6:18 AM: dressing dry and intact on left leg. - An LPN note dated 1/3/2017 at 2:18 PM: seen by nurse practitioner (NP), the wound was assessed and a dry clean dressing was applied. - An RN skin/wound note dated 1/5/2017 at 1:41 PM: the resident had 2 v shaped lacerations measuring 3 cm x 3 cm, and 1.5 cm x 1.5 cm. The NP evaluated the resident in the past 2 days and was evaluating today. The sutures were clean, dry, and intact. A new order was obtained for [MEDICATION NAME] (antibiotic ointment) to the area. There was no documented evidence of an NP note on 1/3 or 1/5/2017. The 1/6/2016 Treatment Administration Record (TAR) documented to: - Cleanse left lower leg with normal saline, pat dry with sterile 4 x 4, and apply [MEDICATION NAME] to wound bed daily and as needed. - Cover with non-adherent dressing and wrap with Kerlix (stretch gauze). - Offload as tolerated. The physician order [REDACTED]. The LPN notes on 1/9/2017 at 3:05 PM, 7:16 PM, and 9:27 PM documented that Keflex was not delivered from the pharmacy. The resident's record did not document if the physician was notified that Keflex was not available. The Medication Administration Record [REDACTED]. The NP note dated 1/10/2017 at 11:28 AM documented the resident was seen 1/9/2017 and the sutures were removed that day. The surrounding skin was red and warm to touch. There was no drainage or [MEDICAL CONDITION] (swelling) and wound edges were approximated. The plan was to treat left leg [MEDICAL CONDITION] with Keflex. The 1/2017 MAR indicated [REDACTED]. The RN note dated 1/24/2017 at 8:15 AM documented the resident's left lower leg was very red and hot to touch. The resident had a history of [REDACTED]. The NP note dated 1/24/2017 documented to start [MEDICATION NAME] (antibiotic) for left leg redness and warmth. If there was no improvement in 24 hours, [MEDICATION NAME] (antibiotic) would be added. The physician order [REDACTED]. During an observation on 1/30/2017 at 12:15 PM, the resident's lower left leg suture line was healed. The lower left outer leg was bright red, shiny, and warm to touch from below the knee to above the ankle of the lower left outer leg. During an interview with NP #25 on 1/31/2017 at 10:15 AM, she stated she first saw the resident's wound around 1/3/2017 and it was a bad laceration. The resident's skin color was normal at that time and she added a [MEDICATION NAME] dressing. She stated she expected nursing to write a daily nursing note documenting color, drainage, and swelling to the area, and also to document if the resident was running a fever. During an interview with RN Manager #24 on 1/31/2017 at 10:30 AM, she stated for a resident with sutures, she expected nursing to look for redness and swelling and to document a daily nursing note. She stated she was not aware that had not been done. She stated when the resident's medication was not available for 2 doses on 1/9/2017, she expected nursing or pharmacy to adjust the stop date so the correct amount of doses were given. 3) Resident #13 was admitted [DATE], and had [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had full cognition, required extensive assistance with most ADLs, had a surgical wound, and received insulin injections daily. The vascular surgery discharge summary dated 11/15/2016 documented the resident had a right third toe amputation on 11/7/2016, she was non-compliant with her diabetic regimen, and was discharged to the nursing home on 11/15/2016. The summary documented she was on [MEDICATION NAME] (long-acting) insulin 24 units nightly, and [MEDICATION NAME] (rapid-acting) insulin with meals using a sliding scale (amount of insulin given based on blood sugar levels). The comprehensive care plan (CCP) dated 11/15/2016 documented the resident had potential for skin impairment and fluid deficit, and had activities of daily living (ADLs) deficit related to amputation of right third toe. Interventions included encouraging good nutrition and hydration, eating independently after set up, obtaining and monitoring blood work as ordered by the physician, and reporting results to the physician for follow up. The CCP did not address the resident's management of diabetes or interventions for uncontrolled blood sugar levels. The 11/15/2016 physician orders [REDACTED].>- [MEDICATION NAME]24 units subcutaneous (subQ, below skin) at bedtime; - [MEDICATION NAME] (fast-acting) insulin 3 units subQ before meals; - No concentrated sweets diet; and - Follow facility hypoglycemic (low blood sugar) and diabetic protocols. The orders did not document to check blood sugar levels and there was not a sliding scale as documented in the discharge summary. The 11/2016 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Blood sugar levels (normal 70-140) were checked 3 times a day at the time of the [MEDICATION NAME] injection and ranged between 135 and 555, and frequently were above 300. There was not a sliding scale or any parameters to call the physician. There was no documentation the physician was notified when the blood sugar was consistently elevated. The admission history and physical examination [REDACTED]. She had diabetes, her diabetes was out of control, and she was non-compliant with diabetes. The registered nurse (RN) progress note dated 11/30/2016 at 8:37 AM documented the physician was called when the resident fell and her blood glucose level was 501. Orders were obtained to send the resident to the hospital and to call the physician when the resident returned from the hospital. The licensed practical nurse (LPN) progress note dated 12/1/2016 at 4:57 PM documented the resident returned from the hospital and there were no new orders. The vascular surgery consult dated 12/2/2016 documented the resident's wound was healing slowly and she was stable. The 12/2016 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 24 of 45 occasions, the blood sugar was greater than 400 and there was no documented evidence the physician was notified. The RN progress note dated 12/15/2016 at 1:47 PM documented the RN was called to see the resident for altered mental status, and the resident was alert and oriented at the time of the assessment. The note documented the physician was made aware of the resident's behaviors, her mental status assessment, and high blood sugar levels. The note documented new orders were obtained. The physician orders [REDACTED]. The physician progress notes [REDACTED]. The RN progress note dated 12/18/2016 at 6:14 PM documented the resident had a blood sugar level of 403. The physician on call was notified the resident did not have any blood sugar level or sliding insulin scale orders, and the physician stated to monitor the resident for now. The LPN progress note dated 12/19/2016 at 2:51 AM documented the resident had only routine insulin orders, needed blood sugar level orders, and was very confused. There was no documented call to the physician or new orders for blood sugar level testing or parameters. The wound care specialist evaluation dated 12/23/2016 documented the resident was post-surgical amputation of her right foot, was a smoker and diabetic, was fully oriented, and had no blood flow to the right foot (measured by Doppler ultrasound). The evaluation documented the resident would be referred back to vascular surgery. The LPN progress note dated 12/29/2016 at 12:16 PM documented the resident continued to have elevated blood sugar levels, and was non-compliant with diet. The physician order [REDACTED]. The orders documented to administer for blood sugar 70-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351-400 = 10 units, and if 401 or greater = 12 units and to call the physician or NP. The wound care specialist evaluation dated 12/30/2016 documented the resident's right foot was autoamputating (becoming gangrenous), was discolored more than half-way and cold, it could not be healed due to no blood flow, and she needed a vascular surgery consult. The hospital discharge summary dated 1/17/2017 documented the resident had a right above knee amputation on 1/10/2017. The summary documented the resident received [MEDICATION NAME]routinely, and [MEDICATION NAME]3 times a day according to a sliding scale. During multiple observations of the resident during survey from 1/24 to 1/31/2017, the resident was alert, had a right above the knee amputation, was compliant with care, and was observed being compliant with her diet. When interviewed on 1/26/2017 at 2:40 PM, LPN #36 stated she worked the unit for 3 weeks on day shift and remembered the resident's blood sugar levels were very high. She stated there was not an RN Manager assigned to the unit at that time, and the facility had RN Supervisors covering the unit. She stated the resident's blood sugar level was 551 one morning and she talked to the NP about an insulin sliding scale. She did not remember if one was obtained or if she documented the conversation. When interviewed on 1/30/2017 at 9:34 AM, RN Supervisor #12 stated the admitting RN should review the discharge paperwork and call the physician to verify orders from the discharge summary. She stated sometimes things got missed. She stated discharge paperwork did not come with an insulin sliding scale at times, and it should be discussed with the physician if missing. She stated that uncontrolled diabetes could play a part in further circulatory issues in diabetics. When interviewed on 1/30/2017 at 3:15 PM, the NP stated she expected the nurses to call if a resident was on long-acting insulin and did not have fast-acting insulin sliding scale coverage. She stated an uncontrolled diabetic would have difficulties with wound healing. When interviewed on 1/30/2017 at 3:40 PM, the Director of Nursing (DON) stated she expected staff to call for insulin sliding scale orders if the resident was on regular insulin. She stated both RNs and LPNs could obtain physician orders, and LPN charge nurses were running the units at that time. 10NYCRR 415.12

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure appropriate treatment and services were provided to 3 of 7 residents (Residents #7, 22, and 26) reviewed for Foley catheters (flexible tube passed through the urethra into the bladder to drain urine). Specifically: - Resident #7 had a Foley catheter that was not ordered, did not receive catheter care, and subsequently developed a urinary tract infection [MEDICAL CONDITION]. - Resident #22 had a Foley catheter without a documented order or documented catheter care for 6 weeks. - Resident #26 had a Foley catheter drainage bag that was not emptied on 2 days of survey. This resulted in actual harm that is not immediate jeopardy for Resident #7. Findings include: 1) Resident #7 was admitted [DATE], and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 12/9/2016 and updated 12/28/2016, documented the resident's cognition was intact. She had a Foley catheter for urinary management and was incontinent of bowel. The hospital discharge summary dated 12/2/2016 documented the resident had a Foley catheter placed for septic shock when in the intensive care unit (ICU). A trial to remove the catheter was unsuccessful and the resident was discharged with the catheter. The physician documented with improved ambulation and physical therapy, a trial would probably be successful at a later time. The comprehensive care plan (CCP), initiated 12/2/2106 and last revised 1/26/2017, documented the resident required total assistance with toilet transfer. The CCP did not document bowel or bladder deficits and did not document the resident had a Foley catheter. The nursing admission screening/history dated 12/2/2016 documented the resident was cognitively intact and had a Foley catheter. The physician's admission orders [REDACTED]. The physician's admission note dated 12/6/2016, documented the resident was admitted for short term rehabilitation and the plan was to remove the Foley when she was stronger. The monthly nursing evaluation dated 12/6/2016 documented the resident was incontinent of bowel and bladder. It did not document the resident had a catheter. A nursing progress note dated 12/7/2016 documented the Foley catheter was intact and draining. The physician progress notes [REDACTED]. A nursing progress note dated 1/20/2016 documented the resident had dark reddish urine, the Supervisor was paged twice with no response, and 2 registered nurses (RNs) were told. During a review of the resident's record on 1/25/2017 at 8:30 AM, there was no evidence found of a physician's orders [REDACTED]. On 1/24/2017 at 10:20 AM, the resident was observed in bed with a covered Foley drainage bag hanging from the bed, and there was cloudy yellow urine in the tubing. On 1/25/2017 at 7:30 AM, the resident was observed in bed with the Foley bag covered and hanging from the side of the bed. There was a strong foul urine odor present. When interviewed, the resident stated the Foley catheter was put in when she was in the hospital and had not been changed. She stated there had been no attempts to remove the Foley, and neither the bag nor the catheter had been changed since admission. The nurse practitioner (NP) progress note dated 1/26/2017 at 4:40 PM documented the resident was seen for a rash on her abdomen. The resident had an indwelling Foley with strong-smelling urine, and the plan was to change the catheter and obtain a urine culture. A laboratory report dated 1/30/2017 documented the resident's urine was positive for a UTI, with over 100,000 CFU/ml (colony-forming units/milliliter) of E. coli. The nursing progress note dated 1/30/2017 at 10:35 AM documented the resident was started on an antibiotic for a UTI. When interviewed on 1/26/2017 at 1:40 PM, certified nurse aide (CNA) #19 stated he did not know if the resident's Foley catheter or catheter bag was ever changed. He stated the nurse was responsible for changing the catheter and bag, and the CNA provided catheter care. He stated catheter care included emptying the bag every shift, and sanitizing the drain spout with alcohol and putting it in the holder. He stated it was not on the care instructions, as the care instructions for all residents were rarely updated. When interviewed on 1/30/2017 at 11:58 AM, licensed practical nurse (LPN) #30 stated when a catheter was scheduled to be changed on a routine basis, it would appear on the treatment administration record (TAR). She stated if it needed to be changed for a reason other than scheduled, she would write a nursing progress note. She stated she did not recall any attempts to remove the resident's Foley catheter since admission and did not know when it was last changed. She reviewed the resident's record and stated there was an order written [REDACTED].>When interviewed on 1/30/2017 at 3:05 PM, the physician stated when a resident was admitted with a Foley catheter, he tried to remove it as soon as possible. He stated he thought the resident's catheter was discontinued and did not know what transpired. He stated having a catheter in without catheter care certainty did not help prevent infection. When interviewed on 1/31/2017 at 10:35 AM, the Assistant Director of Nursing (ADON) stated if the resident came to the facility with a catheter, it should be put in the physician's orders [REDACTED]. While reviewing the CCP, she stated she initiated the CCP and there was not a plan for catheter care. She stated the staff would know to do catheter care when they saw the resident's Foley catheter, and a nurse should have notified the physician for an order. When interviewed on 1/31/2017 at 2:45 PM, NP #21 stated she was asked to look at a rash on the resident's abdomen on 1/26/2017. She stated when she observed the rash, she noticed the resident had a catheter and the urine looked dirty and smelled foul. She stated she told the staff to change the catheter and then send a specimen to the lab. She stated if catheter care was given, it was highly likely that the UTI could have been prevented. 2) Resident #22 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired, and she was occasionally incontinent of urine. The MDS did not document the resident had a Foley catheter. The nursing admission screening/history dated 11/9/2016 documented the resident was alert and oriented and had a Foley catheter. The physician's admission history and physical examination [REDACTED]. The physician wrote that it was recommended the Foley be discontinued at the nursing home, although it was not clear the patient would tolerate Foley discontinuation. On physical examination, the Foley was in place and draining clear yellow urine. The nursing progress note dated 11/22/2016 at 1:44 PM documented the resident had a Foley catheter. The 11/2016 Treatment Administration Record (TAR) did not document the resident was provided Foley catheter care. The nursing progress note dated 12/6/2016 at 12:25 PM documented another nurse was getting an order for [REDACTED].>The physician progress notes [REDACTED]. The note did not document the resident had a Foley catheter. The physician orders [REDACTED]. The nursing progress note dated 12/29/2016 at 7:25 AM documented the resident's Foley catheter was changed on 12/28/2016. The 12/2016 TAR documented the resident received catheter care every shift starting on the evening shift of 12/28/2016. There was no catheter care documented from 12/1 through 12/27/2016. The physician order [REDACTED]. During a review of the resident's medical record on 1/26/2017 at 4:00 PM, there was no evidence found of an order for [REDACTED]. During an observation on 1/27/2017 at 9:25 AM, the resident was in bed sleeping and an uncovered Foley drainage bag with clear yellow urine hung on the bedside. When interviewed on 1/26/2017 at 2:30 PM, a family member stated the resident lived with her the year prior to the nursing home admission and did not have a Foley catheter. She stated she did not know why the resident had the Foley, and it was initially put in at the hospital. She stated they did not change the catheter until she questioned the staff about it when she thought the resident had a UTI. She also stated she did not know who the resident's physician was. When interviewed on 1/30/2017 at 11:58 AM, licensed practical nurse (LPN) #30 stated the resident was admitted with a Foley catheter on admission and there had been no attempts to discontinue it. She stated when Foley catheter care was given, it was documented on the TAR. She stated if the catheter or drainage bag was changed, it would be documented on the TAR or in the nursing progress notes. When interviewed on 1/30/2017 at 12:10 PM, registered nurse (RN) #24 stated when a resident was admitted , the RN reviewed orders from the hospital discharge summary, and called the physician and got admission orders [REDACTED]. She reviewed the resident's record and stated there was not an order for [REDACTED]. When interviewed on 1/30/2017 at 3:05 PM, the physician stated Foley catheters were used in the nursing home for residents with [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], inability to void, and bad wounds. He stated when residents came from the hospital, he usually tried to discontinue the catheter as soon as possible. He stated he did not recall what the plan was for Resident #22's Foley catheter. He also stated if the resident had a Foley catheter and there was not an order, he would expect the nurse to call and obtain an order. 3) Resident #26 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. He required extensive assistance with activities of daily living (ADLs), and had a Foley catheter. The physician's orders [REDACTED]. - Indwelling Foley catheter 18 French (F, size), 10 cubic centimeters (cc) balloon. Change monthly. - Change leg bag/straight drainage bag weekly. Catheter care every shift. The comprehensive care plan (CCP) dated 12/5/2016 documented the resident had a Foley catheter. Interventions included catheter care every shift, check tubing for kinks, monitor and document output, and monitor for UTI. The undated certified nurse aide (CNA) care guide documented the resident had a Foley catheter and a leg bag with leg strap when out of bed. Catheter care was to be provided in the morning and evening, and as needed. During an observation on 1/24/2017 at 1:55 PM, the resident's straight drainage bag was hung on his nightstand next to his bed. The drainage bag was not attached to the resident and was filled one-quarter full of yellow urine. At 5:27 PM, the resident was seated in his wheelchair in his room, stating he was cold. The drainage bag was still hung on the nightstand and had not been emptied. During an observation on 1/26/2017 from 9:02 - 9:49 AM, the resident was asleep in bed. At 1:47 PM, the resident was not in his room. The straight drainage bag was hung from the bottom of the resident's bed and it was half-full with yellow urine. The tubing of the bag was draped through the bottom drawer of his nightstand and the tip of the catheter tubing was uncovered. During an interview with CNA #62 on 1/30/2017 at 2:00 PM, she stated she was assigned to the resident on 1/26/2017 and she was floated to the unit that day. When asked what care she provided to the resident's Foley catheter that day, she stated she did not remember him or what type of care she provided that day. During an interview with licensed practical nurse (LPN) Charge Nurse #26 on 1/31/2017 at 8:30 AM, she stated the resident was capable of being able to be switched from the straight drainage bag to the leg bag after he woke up. The CNAs were responsible to empty the straight drainage bag and it was to be rinsed out and hung in the bathroom. She stated she did not expect the bag to remain hanging with urine during the day and it could expose the resident to possible infection. During an interview with registered nurse (RN) Manager #24 on 1/31/2017 at 10:30 AM, she stated the straight drainage bag should be emptied and rinsed, the tubing should be capped, and the bag put in an area away from infection. She stated she would not expect urine to remain in the bag after the resident woke for the day. 10NYCRR 415.12(d)(2) (

Based on observation, record review, and interview conducted during the abbreviated surveys (#NY 362 and NY 940), it was determined for 2 of 7 residents (Residents #1 and 2) reviewed for pressure ulcers, the facility did not ensure that a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer, and did not ensure residents having pressure ulcers received the necessary treatment and services to promote healing. Specifically, for Resident #1, the facility did not ensure accurate skin assessments were consistently performed and documented, did not adequately monitor pressure sores, and did not consistently implement physician-ordered treatments. Subsequently, Resident #1 developed two pressure ulcers on his sacrum, and one on each heel, each of which continued to worsen. This resulted in actual harm that was not immediate jeopardy for Resident #1. For Resident #2, treatment with the physician-ordered wound vac (negative pressure wound therapy) to the resident's sacral wound was stopped on 7/19/2016, and there was no physician order to discontinue the wound vac and for a new treatment to her wound until 8/2/2016. Findings include: The facility's Skin Impairment and Wound Prevention/Management Policies and Procedures, dated 1/2014, documented that the nurse manager, or designee, was responsible for the implementation, coordination, and monitoring of the skin care protocols on each unit. The nurse manager/designee will be responsible for assessing, staging, measuring, and the documentation of each skin impairment each week until resolved. The Weekly Skin Condition Report policy (undated) documented that a weekly Pressure Ulcer Progress Report will be initiated for each individual impairment identified. The Wound Record serves as the CCP for each ulcer area. The monitoring of ulcer areas all be continued until 4 weeks after the area was identified as Healed. The policy documented the Skin Care Team/designee will see weekly all residents with Stage III or IV pressure areas and Stage I areas that have progressed to a Stage II severity. The Skin Care Protocol for Stage III and Stage IV Pressure Ulcer policy (undated) documented to place a mattress specifically for Stage III - IV on the bed. Notify the DON/Skin Nurse for help locating this type of mattress. The facility's Skin Impairment and Wound Prevention/Management Policies and Procedures, dated 1/2014, contained a Skin Care Team policy. The policy documented the Skin Care Team would consist of the DON (Director of Nursing), ADON (Assistant Director of Nursing), Nursing Supervisor, Skin Nurse, Dietitian or designee, Unit Managers, Nurse Practitioner, Primary Care CNA (certified nurse aide) and others as appropriate, and physical and occupational therapy, as appropriate. The team was to meet weekly in each building, so that monthly every resident who had a Stage I, or greater, would be reevaluated by the Skin Care Team. The evaluation was to include a visualization of the pressure ulcer, evaluation of treatment protocols, and a review of the resident's medical record, including review of the Wound Record and weekly Wound Tracking Record, CCP (Comprehensive Care Plan), lab values, turning and positioning records, nutritional assessment, and a risk assessment on the initial visit. A newly identified pressure area will be assessed by an RN (registered nurse) on the day of discovery, and implementation of treatment, progress note, CCP, CNA, and all other members of the team, as appropriate, would evaluate newly identified impairments within 2 business days of discovery. The policy documented that the nurse manager would provide written feedback to the DON regarding the recommendations of the team within 1 calendar week. 1) Resident #1 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Nursing Admission Screening/History, dated 3/29/2016, documented the resident's left buttock had a Stage II (partial thickness skin loss) pressure ulcer measuring 1.5 cm (centimeters) x 0.5 cm x 0.1 cm, and a treatment was ordered or required. The notes documented bordered gauze dressing to the resident's buttock. Physician #1's Admission history and physical examination [REDACTED]as indicated on the Nursing Admission Skin Assessment. The CCP dated 3/29/2016 documented the resident had actual skin impairment to his right heel. There were no documented interventions, other than dietary. The CCP did not identify the pressure ulcer on the resident's left buttock. The Weekly Wound Report, dated 3/30/2016, documented the resident had an area on his left sacrum (triangular area at base of spine), and the resident was not on the unit, as he was out at [MEDICAL TREATMENT]. There was no documented assessment of the area on the resident's left sacrum. The Weekly Wound Report did not contain documented evidence of the pressure ulcer on the resident's right heel that was identified on his 3/29/2016 CCP. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. He required extensive assistance for bed mobility, transfers, hygiene, toileting, and dressing. The MDS documented the resident was at risk for pressure ulcers, and had one Stage II pressure ulcer that was present upon admission to the facility. The MDS assessment documented the resident had a pressure relieving device for his chair and bed, was on a turning and positioning program, and received pressure ulcer care. These interventions were not in place on the resident's CCP. The Weekly Wound Report, dated 4/6/2016, documented the resident had an area on his left sacrum measuring 2.4 cm x 1.7 cm, and the wound bed was described as eschar (dry dead tissue). The report documented the PU (pressure ulcer) II was resolved, and the treatment was changed to [MEDICATION NAME] (therapeutic ointment). The Weekly Wound Report did not contain documented evidence of the pressure ulcer on the resident's right heel that was identified on his 3/29/2016 CCP. The Weekly Wound Report, dated 4/13/2016, documented the pressure ulcer on the resident's left sacrum was resolved and [MEDICATION NAME] was the documented treatment. The Weekly Wound Report again did not contain documented evidence of the pressure ulcer on the resident right heel that was identified on his 3/29/2016 CCP. Physician #1's Readmission history and physical examination [REDACTED]. Upon nursing home readmission, he had a Stage II pressure ulcer with eschar on his left sacrum as documented on the Nursing Admission Skin Assessment. The Nursing Admission Screening/History, dated 4/19/2016, documented the resident had a Stage II left sacrum pressure ulcer from a previous admission that was resolving. It was documented that eschar was present, there were no documented measurements of the pressure ulcer, and a treatment was ordered or required. The Order Review Report documented that on 4/19/2016 the following physician orders were written: - a nurse skin inspection weekly each Friday day shift, every Monday and Wednesday evening shift, and every Wednesday and Friday night shift. This was to be started on 4/20/2016. - TEDs (compression stockings) were to be applied each morning, and removed each evening. This was to be started 4/20/2016. - [MEDICATION NAME] ointment 0.44-20.6% applied to the resident's buttocks, sacrum, and coccyx topically daily for a rash. - Lac-Hydrin lotion (hydrating lotion) 12% applied to the resident's dry skin every 12 hours as needed. The Weekly Wound Report, dated 4/20/2016, documented the resident had Stage II pressure ulcer on his left sacrum, measuring 0.4 cm x 0.4 cm, and the wound bed was described as eschar. The report documented treatment was [MEDICATION NAME]. The Weekly Wound Report, dated 4/27/2016, documented the resident had an area on his left sacrum, that measured 0.3 cm x 0.4 cm, and the wound bed was described as eschar. The report documented the pressure ulcer was resolved x 1 week and the treatment was [MEDICATION NAME]. The Weekly Wound Report, dated 5/4/2016, documented the pressure ulcer on the resident's left sacrum was healed x 1 week, and the treatment was [MEDICATION NAME]. There were no further Weekly Wound Reports for 5/2016. Registered nurse (RN) unit manager #8's nursing progress note dated 5/4/2016 at 8:00 AM documented a late entry, wound rounds completed. The Stage II left sacral pressure ulcer was resolved x 2 weeks. Weekly skin observation will continue. RN unit manager #8's nursing progress note did not document the date of the observation. Licensed practical nurse (LPN) #8's nursing progress note dated 6/8/2016 documented a quarter size open area on the resident's right heel, and the NP (nurse practitioner) was notified. The last time the right heel wound was documented was upon admission on 3/29/2016. There was no documented evidence an assessment was done of the area on the resident's right heel by a qualified person. The MDS assessment dated [DATE] documented the resident was at risk for the development of pressure ulcers, and he did not have pressure ulcers per clinical assessment. The assessment documented the resident had a pressure reducing device for his chair and bed, and was on a turning and repositioning schedule. These interventions were not on the resident's CCP. Physician #1's progress note dated 6/14/2016 did not contain documented evidence of the pressure ulcer on the resident's right heel, or the resolved pressure ulcer on his sacrum. LPN #10's nursing progress note dated 6/21/2016 at 3:24 AM, documented the resident complained of right heel pain. RN unit manager #11's nursing progress note dated 6/21/2016 documented staff requested an assessment of the resident's bilateral heels. The RN unit manager documented: - a 1.5 x 1.5 x 0.0 area was noted on the resident's left heel. The area was possible pressure, versus venous (slow blood flow) ulcer. Will consult with the NP for an order for [REDACTED].>- a 1.5 x 2.0 x 0.2 open Stage II area on the resident's right heel. The Order Review Report dated 6/21/2016 documented a physician order to consult with the Wound Care physician for an evaluation and ongoing treatment of [REDACTED]. The Provider Pressure Ulcer Assessment and Orders, (Wound Care consultant's assessment) dated 6/22/2016, documented an initial consult for the resident's heels. The assessment documented: - the resident's right heel wound was 90% granulation (healing tissue) and 10% slough (yellow stringy tissue) and measured 1.5 cm x 2.0 cm x 0.1 cm. The recommended treatment was Alginate (absorbent dressing) and silver [MEDICATION NAME] (absorbent dressing) daily and prn. - the resident's left heel was 30% granulation and 70% slough, and measured 1.5 cm x 1.5 cm x 0.1 cm. The recommended treatment was a nickel-thick layer of Santyl ([MEDICATION NAME] ointment) applied to the areas, and covered with a moist wet gauze daily and prn (as needed); and - Lac-Hydrin to be applied to the resident's legs. The Order Review Report documented a physician order written [REDACTED]. - cleanse the resident's right heel with normal saline, pat dry with a sterile DSD (dry sterile dressing), and apply alginate to the wound bed daily and as needed. Cover with a dry clean dressing and offload as tolerated, and as needed. - cleanse the the resident's left heel wound bed with normal saline, pat dry with a sterile 4 x 4, and apply Santyl to the wound bed daily and as needed. Cover with Ag [MEDICATION NAME] (antimicrobial absorbent dressing), and offload as tolerated. - Prevalon boots (protective boots) on daily and off evenings. ADON #12's nursing progress note dated 6/27/2016 documented she was asked by the LPN to assess the resident's sacrum, and the resident had two Stage III (full thickness skin loss) pressure ulcers. The pressure ulcer on the resident's left sacrum measured 3.4 x 2.4 x 0.2 and the pressure ulcer on the right sacrum measured 4.6 x 2.1 x 0.2. The ADON documented she spoke to the NP; treatment orders and a consult for the Skin Care physician were added. The Order Review Report documented a physician order dated 6/27/2016 to cleanse the resident's left buttock with normal saline, pat dry with a sterile 4 x 4, and apply Ca (calcium) Alginate to the wound bed daily, and as needed. Cover with a DCD (dry clean dressing) and picture frame with [MEDICATION NAME]. Off load as tolerated, and as needed. The report documented this order was discontinued on 7/14/2016. The Provider Pressure Ulcer Assessment and Orders, dated 6/29/2016, documented an assessment of the resident's heels: - the resident's right heel was 100% granulation and measured 3.2 cm x 6.5 cm x 0.1 cm. (This measurement was over twice as large as the measurement documented on 6/22/2016.) The recommended treatment was Alginate daily and prn. - the resident's left heel was 100% granulation and measured 2.5 cm x 6.5 cm x 0.1 cm. (This measurement was also much larger than the measurement documented on 6/22/2016.) The recommended treatment was Alginate daily and prn. - Lac-Hydrin was to be applied to the resident's legs BID; and - there was no documented evidence the provider assessed the pressure ulcers on the resident's sacrum that were documented by ADON #12 on 6/27/2016. The Order Review Report documented a physician order dated 6/29/2016 for Lac-Hydrin Lotion 12% to the resident's lower legs twice a day. The Order Review Report documented a physician order dated 6/30/2016 to discontinue the TED compression stockings. The Order Review Report documented a physician order dated 7/1/2016 to cleanse the resident's left heel with normal saline, pat dry with a sterile 4 x 4, and apply calcium alginate to the wound bed daily and as needed. Cover with DSD and picture frame with [MEDICATION NAME] and offload as tolerated and as needed. The Date Wound Tracking Form dated 7/6/2016 documented the resident had the following wounds: - Stage III pressure ulcer to his right heel measuring 3.0 cm x 3.5 cm x 0.1 cm; - Stage III pressure ulcer to his left heel measuring 1.6 cm x 1.0 cm x 0.1; - the wound bed of the right and left heel was described as granulation and the treatment was alginate; and - there was no documented evidence the pressure ulcers on the resident's sacrum were tracked. LPN #5's nursing progress note dated 7/10/2016 documented the resident refused the ordered treatments to his right and left heels, and right and left buttocks. The Date Wound Tracking Form dated 7/13/2016 documented the resident was at [MEDICAL TREATMENT]. Handwritten in red on the back of the form documented: - R 2.4 x 2.0 x 0.1 (unit of measure not specified); - L 1.4 x 0.9 x 0.1 (unit of measure not specified); - sacrum 6.9 x 4.5 x 0.5 (unit of measure not specified); and - the words Santyl, [MEDICATION NAME], zinc, silver, and [MEDICAL TREATMENT] were written below the measurements, with a question mark written to the right of the word silver. LPN #3's nursing progress note dated 7/13/2016 documented the resident continued with open areas on both his heels and also a very large area on his coccyx. The Wound Care physician was to see the resident, but the resident was out at [MEDICAL TREATMENT]. The progress note documented that LPN #3 spoke to the physician and he would be back next Wednesday early to see the resident, and in the meantime his nurse was to come and assess the area. LPN #3's nursing progress note dated 7/14/2016 documented the wound nurse came up to see the resident, as the resident was unable to be seen on 7/13/2016. The bilateral heels continue with the same treatment, the areas are healing slowly. Large necrotic tissue came off with dressing removal, the area was red and clean, scant serous drainage was noted. The resident had a new area to his buttocks and was phoned into the Wound Care physician with the measurements (which were not documented). The Date Wound Tracking Form dated 7/14/2016 documented the measurements were called into the Skin Consultant. The form did not contain measurements, or a description of the resident's wounds. The Order Review Report documented a physician order dated 7/14/2016: - check the inflation of the EZ Air Function every shift. - starting 7/15/2016, apply Santyl 250 units/gram to the resident's sacral wound every day related to [MEDICAL CONDITION] (chronic) (peripheral). The wound bed was to be cleansed with normal saline and patted dry with a sterile 4 x 4. Santyl was to be applied to the wound bed, then covered with [MEDICATION NAME] Ag daily and as needed, and covered with bordered gauze. LPN #5's nursing progress note dated 7/17/2016 documented the resident refused the treatments to his sacral wound, and right and left heels. Physician #2's progress note dated 7/19/2016 documented the resident was transferred to another unit in the facility, and the resident's skin had active sacral and both heel pressure ulcers on transfer admission. The progress note provided inconsistent documentation, as the progress note documented the resident's skin revealed no pressure ulcers. The physician's documented Assessment/Diagnoses/Care Plan included, for the resident's chronic persistent pressure ulcer, this is probably nonavoidable in view of the resident's immobility and chronic illness with multiple comorbidities. The Date Wound Tracking Form dated 7/20/2016, documented the resident had the following wounds: - Stage III pressure ulcer to his sacrum measuring 4.2 cm x 2.5 cm, and the wound bed was eschar. The documented treatment was zinc oxide and skin prep. - Stage III pressure to his right heel measuring 1.2 cm x 9.0 cm, and the wound bed was eschar. The documented treatment was skin prep. - the wound beds of the right and left heels were described as granulation, and the treatment was alginate. The Order Review Report documented a physician order dated 7/25/2016: - 1 ounce Pro Source No Carb (dietary supplement) 3 times a day for a Stage III pressure ulcer; and - 500 mg (milligrams) [MEDICATION NAME] acid tablet daily for wound healing. The Order Review Report documented a physician order dated 7/26/2016: - Lac-Hydrin Lotion 12% to the resident's lower legs twice a day was discontinued; and - Lac-Hydrin Lotion 12% to the resident's lower legs on the day and evening shifts. NP #14's progress note dated 7/26/2016 at 5:21 PM documented she was asked to see the resident, as he had a fever of 103, his heel wounds had worsened, and he developed a new sacral ulcer. The NP documented the Wound Care physician gave orders for the sacral treatment, a new dressing was applied, and the NP did not see the area. The NP documented she was doing [MEDICAL CONDITION] work-up on the resident, including a chest x-ray, U/A C&S (urine tests), CBC and BMP (lab tests), and blood cultures. IV (intravenous) fluids were started, and the Wound Care physician would see the resident in the morning. The Date Wound Tracking Form dated 7/27/2016 documented the resident had the following wounds: - Stage III pressure ulcer to his left gluteal (buttock) measuring 4.2 cm x 1.0 cm x 0.1 cm. The wound bed was granulation, and alginate was the documented treatment. - unstageable pressure ulcer to his sacrum measuring 10.0 cm x 5.0 cm, and the wound bed was eschar. The documented treatment was alginate. - unstageable pressure to his right heel measuring 3.6 x 5.3 cm, and the wound bed was eschar. The documented treatment was skin prep. - unstageable pressure to his left heel measuring 1.5 cm x 7.0 cm, and the wound bed was eschar. The documented treatment was skin prep. During an interview with LPN #7 on 8/17/2016 at 12:00 PM, she stated that her title in the facility was LPN Wound Care Nurse. She stated she started her day at 7:00 AM and worked until whenever, and clarified this to mean between the hours of 3:00 PM - 6:00 PM 5 days a week. LPN #7 stated she thought she was to do treatments in the facility, and this was not the case, as on weekends she was placed on a medication cart because the facility was short-staffed. LPN #7 stated that she had no training in her job, and made up her own system as what to do. LPN #7 stated she did not know the facility skin policy, and added she did not even have a job description. LPN #7 stated she knew Resident #1 from the short term rehab unit, he transferred to long-term care, and somehow he landed up on the wound list. LPN #7 stated the process was broken, as she found out by way of mouth that the resident had a pressure ulcer on his coccyx when she received a text from LPN #3 on the 13th, stating the resident's treatments did not match his wounds. When asked what treatments she did, LPN #7 responded that she could not do everyone in the facility, and that she did the heavy hitters. She added she communicated with the nurse which treatments she would do, or she would get an overhead page to do a treatment, and if she could do it she would. During an interview with ADON #12 on 8/22/2016 at 10:15 AM, she stated that she oversaw skin, and it was the responsibility for the covering RN to ensure orders are carried out. The ADON stated there was a skin policy, and to the best of her knowledge it was followed. The ADON stated the LPN Wound Care Nurses were to round with the Skin Care Consultant, and do treatments. The ADON stated she did not review the work of the LPN Wound Care Nurses, unless something was brought to her attention. The ADON stated there was a job description for the Wound Care LPNs. She stated she was not aware it was reported to the surveyor that there was no Skin Care policy or job description for the Wound Care LPNs. During an interview with NP #14 on 9/6/2016 at 1:55 PM, she stated the Wound Care physician was a consultant and he made recommendations for the facility to follow. She stated the ultimate responsibility for communicating changes of the wounds rests with the nurse manager. NP #14 stated the Wound Care physician communicated his recommendations to the facility via the company he works for on wound sheets. When asked what the turnaround time was, the NP stated that's the problem, as the sheets get turned over to the ADON. The NP stated the facility identified 3 weeks ago that there was a problem during a conference call when a Wound Nurse stated that he knew that there were problems with orders, as they were being recommended, and they were not written. The nurse managers stated they did not know where the orders were and the consensus was that the recommendations were in the ADON's office. The NP stated that she firmly believed that if there were more staff, the facility wounds would not be as bad as they are. She stated treatments, and turning and repositioning, were not being done. NP #14 stated that the wounds in the facility have gotten worse, and she could not believe that Resident #1's heels deteriorated in 1 week. During an interview with LPN #5 on 9/14/2016 at 11:00 AM, she stated that if the dressing on the resident's sacrum was dirty on days he went to [MEDICAL TREATMENT], she would apply a normal saline dressing, not the ordered dressing. LPN #5 stated that at times on days she covered the units, she signed that she completed the resident's treatments, when in fact she had not done the treatments. LPN #5 stated she could not recall the specific dates that she documented for care she did not provide. During an interview with RN unit manager #8 on 9/16/2016 at 8:00 AM, she stated that her role in skin was to review the skin books, do weekly skin rounds, and go to the NP to obtain orders for the recommendations made by Wound Care Physician #15. The RN unit manager stated Resident #1 came in to the facility with a couple of pressure ulcers on his bottom. She stated the reason there was no assessment of the resident's sacrum on 3/30/2016 was that the girls said it was resolved, and the RN unit manager clarified girls to mean CNAs. The Weekly Wound Report dated 4/6/2016 was reviewed with RN unit manager #8 and she stated she documented the area on the resident's sacrum was resolved, because the area was not open - it was a healing scab. The RN unit manager stated that she had no orientation and she found out information through asking questions, and observations. The RN unit manager stated she had not seen the facility's Skin policy, and based upon her observations when she started in the facility, the B South unit would only track resolved areas for 2 weeks, and the Wound Care Physician #15 would track areas for 2 weeks after resolution. The RN unit manager stated that she later learned skin was to be followed for 4 weeks after resolution. The RN unit manager stated that she would have expected a CCP for the pressure ulcer on the resident's sacrum, but I had just started on the unit 3/16/2016 and was trying to get things in the charts, and audited all the charts. The RN unit manager stated that she was aware that there were concerns with skin, and she recommended a skin nurse. She stated the facility followed up and promoted a LPN who was good with skin. The RN unit manager stated there were problems related to turning and repositioning related to staffing, as when a unit had 37 residents and 1 LPN and CNAs, it affected the proper turning and positioning of residents on the unit. During an interview with Physician #1 on 9/16/2016 at 10:00 AM, she stated her role in the facility included that of Medical Director, and she was the attending physician for certain residents in the facility. Physician #1 stated her role in skins was that she developed the Skin policy with the former DON, and to help provide good care for residents as she was notified of their skin issues. Physician #1 stated that she was asked to review Resident #1's case and she did not recall the specifics. The Weekly Wound Report dated 4/6/2016 was reviewed with Physician #1 and she stated an area is not resolved if there are dimensions and eschar present. Physician #1 stated her understanding of the role of the LPN Wound Care Nurse was to do dressing changes as ordered, and if there were changes in the condition of the wound to notify the unit manager, who would notify the NP or physician. During an interview with the DON on 9/16/2016 at 2:30 PM, she stated that within the past couple of weeks, her role in skin had been expanded to include the oversight of the skin program. The DON stated that she did not recall the specifics of Resident #1 without reviewing his chart, and she did not have his chart in front of her. The DON stated that she was not aware that at times the treatment nurses would sign they did the resident's treatments and they were not done, and she was not aware that a normal saline dressing was applied to his sacral wound instead of the ordered treatment. The DON stated she felt the facility was working vigorously to improve the treatment of [REDACTED]. The DON stated she was aware the LPN treatment nurse had been pulled from her assigned job title to administer medications, and it was her expectation that when the LPN could not do the treatments, the RNs would do them. During an interview with the Assistant Administrator on 10/25/2016 at 8:23 AM, he stated that he was the Acting Administrator in August 2016, and he did not have any knowledge of Resident #1's skin issues. The Assistant Administrator stated that his understanding of the role of the LPN Wound Nurses was that they would be checking on wounds and changing dressings, and the DON was involved in that process. The Assistant Administrator stated he would have expected the Wound Nurse to be knowledgeable on the facility Skin policy. The Assistant Administrator stated that he was aware the Wound Nurses were pulled from their duties to administer medications to residents; however, the goal was to have the Wound Nurse do treatments. 2) Resident #2 had [DIAGNOSES REDACTED]. The resident's undated care card documented the resident had an Easy Air pressure relieving/reducing mattress, and was turned and positioned every 2 hours and as needed. The resident was to be kept off her sacrum as much as possible. The +care card documented the resident was dependent upon staff for ADLs (activities of daily living). The physician's progress note, dated 6/15/2016, documented the resident had a pressure ulcer and osteo[DIAGNOSES REDACTED] (infection and inflammation of the bone) of the sacral area. The physician's Physical Examination documented the resident's sacral region wound was relatively clean. The resident's CCP (Comprehensive Care Plan), dated 6/26/2016, identified the resident had an actual skin impairment to the integrity of her sacrum, and interventions were implemented, including turning and repositioning every 2 hours, keep clean and dry, Easy Air Mattress, turn and repositioning every 2 hours, and weekly treatment documentation to include measurement of each area of skin breakdown. The 6/27/2016, MDS (Minimum Data Set) assessment, documented the resident had moderately impaired cognition, and was dependent upon staff for ADL's. The assessment documented the resident had an Indwelling Foley catheter (small flexible tube inserted into the bladder to drain urine) and was always incontinent of stool. The assessment documented the resident was at risk for pressure ulcers and she had a Stage IV pressure ulcer that was present upon admission. The physician's progress note, dated 7/12/2016, documented the resident was recently admitted to the facility for a sacral chronic osteo[DIAGNOSES REDACTED] with a Stage IV pressure ulcer, and was under the care of Physician #15 for her pressure ulcer. The physician's orders, dated 7/1/2016, documented the resident was to have a Wound Vac (negative pressure wound therapy) applied to her Stage IV sacral wound at 125 mm/Hg (millimeters of mercury). A normal saline wet-to-dry dressing was to be applied to the wound bed if the Wound Vac was not functioning. The nursing progress note, dated 7/19/2016, documented the Wound Vac was not functioning and was discontinued until reassessed by the physician. The 7/2016 TAR (Treatment Administration Record) documented that a normal saline wet-to-dry dressing was applied to the resident's wound bed on 7/19/2016 - 7/21/2016. The site of the wound was not specified on the TAR. The nursing progress note, dated 7/21/2016, documented the Wound Vac was discontinued and new treatment orders were pending, which were Santyl with [MEDICATION NAME] AG (treatment ointment), covered with CDC (clean dry covering) per provider's assessment. The progress note documented the measurements of the wound bed was 5.2 x 4.6 x 3.2 (unit of measurement was not specified). The nursing progress notes, dated 7/22/2016, documented the Wound Vac was discontinued and new orders were pending from Physician #15. The 7/2016 TAR documented that a normal saline wet-to-dry dressing was applied to the resident's wound bed on 7/22/2016. The site of the wound was not specified on the TAR. The nursing progress notes, dated 7/23/2016 - 7/26/2016, documented the Wound vac was discontinued, not in place, or N/A (not applicable.) The 7/2016 TAR documented that a normal saline wet-to-dry dressing was applied to the resident's wound bed on 7/23/2016 and 7/26/2016. The site of the wound was not specified on the TAR. LPN (licensed practical nurse) #17's nursing progress note, dated 7/26/2016, documented [MEDICATION NAME] was applied to the resident's bilateral hip areas to prevent tissue damage. LPN #'s 13 and 17 nursing progress notes, dated 7/27/2016, doc

Based on observation, record review, and interviews conducted during an abbreviated survey (#NY 865), it was determined the facility did not provide adequate supervision to prevent accidents for 1 of 5 residents (Resident #2) reviewed for falls. Specifically, Resident #2 experienced harm when he fell and sustained lacerations and a subdural hematoma (bruising and bleeding on the brain), as the facility did not ensure the resident's increased supervision (1:1) was consistently implemented as planned. Findings include: Resident #2 had [DIAGNOSES REDACTED]. The RN nursing progress note dated 1/14/2016 documented the resident was admitted to the facility on this date at approximately 3:00 PM, with a [DIAGNOSES REDACTED]. The progress note documented the resident was very unsteady and impulsive, and the fall care plan was updated. The physician's orders [REDACTED]. - 2.5 mg (milligrams) Amlodipine (blood pressure medication) once a day; - 81 mg aspirin; - 40 mg Lasix (diuretic); and - 12.5 mg Seroquel (antipsychotic) at bedtime; The resident's CCP (comprehensive care plan), initiated 1/14/2016 and updated on 1/17/2016, documented the resident was at high risk for falls. Interventions included: anti-skid socks when in bed; floor mat alarm and chair alarm; keep call light within reach; encourage the resident to use it when assistance is needed; and to anticipate and meet the resident's needs. The facility's 24 hour report, dated 1/14/2016 for the 3 PM to 11 PM shift, documented the resident was at risk to fall; had increased confusion; and all alarms were on. For the 11 PM to 7 AM shift, on this same 24 hour report, the resident was was documented to be up all night, trying to scoot out of the chair. The report documented the resident's increased confusion continued and alarms were intact. The resident's CCP documented 1:1 was initiated on 1/15/2016, and entered on the care plan on 1/17/2016. The resident's CNA (certified nurse aide) care card (care instructions) documented the resident was admitted to the facility on [DATE], and 1:1 was initiated on 1/15/2016. Instructions on the care card documented to follow facility fall protocol and use alarming chair alarm. The RN (registered nurse) nursing progress note, dated 1/15/2016, documented she was notified the resident had fallen. The progress note documented staff stated the alarm was sounding and when they looked, the resident was falling to the floor. The 24 hour report dated 1/15/2016 documented the resident fell and went to the hospital on the 3 PM - 11 PM shift. There was no documented evidence on the 24 hour report that the resident received increased supervision. The entry for the 11 PM - 7 AM shift documented the resident was admitted to the hospital. The LPN (licensed practical nurse) nursing progress note, dated 1/16/2016 at midnight, documented the resident fell at approximately 6:30 PM on 1/15/2015, and was transported to a local hospital. It was reported the resident may have possibly been unconscious when he initially fell . The progress note documented the resident sustained [REDACTED]. Hospital records documented the resident was hosptalized on [DATE] to 1/22/2016 for subarachnoid hemorrhage and subdural hematoma related to multiple falls. The hospital notes documented the resident had a poor prognosis, was a poor surgical candidate, and comfort measures were initiated. Medications prolonging his life were discontinued. The resident was discharged to another skilled nursing facility on 1/22/2016. The RN nursing progress note, dated 1/17/2016 as a late entry, documented on 1/15/2016 the resident was given 1:1 supervision due to his history of falls at home. The progress note documented the resident's care plan was inadvertently not updated at that time, but was updated then. The facility Summary of Investigation, dated 1/22/2016, documented the resident was placed on 1:1 on 1/15/2016 on the 3 AM - 3 PM shift, for the purpose of providing a safe environment for him, due to his impulsivity and impaired safety awareness. The facility investigation documented CNA #5 was the assigned to provide 1:1 supervision for the 3 PM - 9 PM shift. At approximately 6 PM, CNA #5 was noted to have had a conversation with CNA #6, about her desire to go on a meal break. CNA #6 agreed to relieve CNA #5. Shortly after this conversation, CNA #6 found the resident was becoming more restless, and she said she was unable to watch him closely enough. CNA #6 transported the resident to the tables in the common area of the chart room. CNA #6 placed the resident up to the table, locked his wheel chair brakes, and saw CNA #5 leave the chart room. CNA #6 said she told CNA #5 she would have to take her break after the resident's dinner, as she (CNA #6) could not perform the 1:1. The ward clerk stated she heard the resident's chair alarm, looked, saw the resident standing, and could not prevent his fall. The investigation documented CNA #5 denied having a conversation with CNA #6 in the chart room. CNA #6 was unavailable for interview and no longer works at the facility. During an interview with the Administrator on 2/2/2016 at 12:40 PM, he stated the facility did not have a 1:1 policy, as it was used on an interim basis. The Administrator stated 1:1 meant constant supervision of the resident. During a follow up interview with the Administrator on 3/8/2016 at 8:25 AM, he stated a policy was written 1/30/2016, titled Visual Monitoring; prior to that date, there was no policy for different levels of resident supervision. He stated the policy was signed by the DON (Director of Nursing), Administrator, and Medical Director on 2/16/2016. During an interview with CNA #5 on 3/8/2016 at 9:15 AM, she stated she was the assigned to provide 1:1 for the resident. She stated she was assigned this job responsibility by the staffing office, and when she wanted to go on break, she had asked who could watch the resident while she was on break. A CNA (CNA #6), who was working both units, offered to watch the resident. CNA #5 stated: - she did not know how breaks were assigned on the 3 PM-11 PM shift, so she asked staff who could cover for her; - she knew she was supposed to notify the nurse when she took a break, but did not in this case, as she did not see the nurse; she said CNA #6 was aware she (CNA #5) was on break; - everyone, except the 1:1, was supposed to help pass trays; - she knew what 1:1 meant, as she worked in health care for many years; and - she was unaware of any 1:1 policy. During an interview with Assistant Nurse Manager #8 on 3/8/2016 at 11:05 AM, she stated there was no log, or other place, to document when 1:1 was provided. She said the only paperwork documenting the name of the 1:1 staff member was on the assignment sheet from the nursing office. During an interview with CNA #9 on 3/8/2016 at 11:10 AM, she stated there was no 1:1 policy. She stated she was knew this, as she was suspended in the past when a Environmental Unit Aide took her assigned 1:1 to therapy and the resident fell . She stated when she asked to see their policy, there was no policy; she was told they would institute one. CNA #9 stated she and a supervisor tried to find a 1:1 policy, and there was not one. During an interview with RN Nurse Manager #12 on 3/8/2016 at 11:45 AM, the Nurse Manager told the surveyor there was no 1:1 policy. 10NYCRR 415.12(h)

Based on observation, record review and interview conducted during the standard survey and abbreviated surveys (NY 915, NY 260, and NY 198), it was determined the facility did not ensure 5 of 30 sampled residents (Residents #3, 5, 8, 15, 17) received the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, - Resident #8 experienced harm when the resident required hospitalization with a fecal impaction, as the facility did not implement the resident's bowel management protocols as ordered by the physician. - Resident #17 did not have blood work test completed as ordered to determine the appropriate [MEDICATION NAME] (a blood thinner, anticoagulant) dosage; did not receive anticoagulant therapy for 6 days after readmission for a [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) in his left leg. Additionally, the facility did not ensure a system was implemented effectively for preventing errors in the transcription of admission orders [REDACTED] - Resident #3's bilateral leg wraps and a Wound V.A.C (vacuum assisted closure) treatments were not documented as completed as ordered; and when the Wound V.A.C. dressing was applied by staff incorrectly, the resident experienced pain. The facility also did not ensure nursing staff were re-trained and their competency checked. - Resident #5's nephrology (kidney-related) consultant's recommendations were not implemented timely or completely (including increasing a diuretic ([MEDICATION NAME]); having daily weights; and having a kidney ultrasound). - Resident #15's multiple wound care clinicians' recommendations were not implemented as planned. When these multiple clinicians had differing recommendations, the facility did not ensure these differing recommendations were communicated to the various outside consultants. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF [DATE]. Findings include: 1) BOWEL CONCERNS: Resident #8 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. - warmed prune or apple juice with a pat of butter melted every morning and [MEDICATION NAME] added if recommended by the registered dietitian (RD) for constipation; - [MEDICATION NAME] solution 30 milliliters (ml) every 24 hours as needed for constipation if no bowel movement in 2 days; - a [MEDICATION NAME] suppository every 48 hours as needed if no bowel movement in 2 days; - a digital rectal exam was to be performed as needed to check for stool on day 3 if no bowel movement and if stool was present, the resident was to be given a Fleets enema. If stool not present, the physician or nurse practitioner (NP) were to be notified. The physician order [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required total assistance for transfers and toileting, and was incontinent. The Bowel Elimination record documented the resident had a bowel movement on [DATE] and did not have bowel movements from [DATE] to [DATE]. The ,[DATE] Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the resident received juice with butter on [DATE] and [DATE]. The Bowel Elimination records documented the resident was incontinent of bowel on ,[DATE], ,[DATE], and [DATE], and did not have a bowel movement from [DATE] to [DATE] and from [DATE] to [DATE]. The ,[DATE] MAR and TAR documented the resident received: - Juice with butter on [DATE], [DATE], [DATE], [DATE], and [DATE]; - [MEDICATION NAME] 30 cc on [DATE]; and - Milk of Magnesia, 10 ml on [DATE]. The MARs and TARs did not document bowel protocol medications were successively administered as ordered when the resident had no bowel movements between ,[DATE] and [DATE] (2 days) and between ,[DATE] and [DATE] (8 days). The Bowel Elimination record documented the resident had a bowel movement on [DATE] and did not have a bowel movement from [DATE] to [DATE]. The ,[DATE] MAR and TAR documented the resident refused juice with butter on [DATE]. The MARs and TARs did not document bowel protocol medications were successively administered as ordered when the resident had no bowel movements between ,[DATE] and [DATE] (4 days). The Annual history and physical examination [REDACTED]. The Bowel Elimination record documented the resident had a bowel movement on [DATE] and did not document the resident had a bowel movement from [DATE] to [DATE]. The ,[DATE] MAR and TAR documented the resident received: - [MEDICATION NAME], 30 ml on [DATE]; and - [MEDICATION NAME] Suppository on [DATE]. The MAR's and TAR's did not document bowel protocol medications were successively administered as ordered when the resident had no bowel movements between ,[DATE] and [DATE] (3 days). The Bowel Elimination Record documented the resident had a bowel movement on ,[DATE] and [DATE] and did not document a bowel movement from [DATE] to [DATE]. The ,[DATE] MAR and TAR documented the resident received: - juice with butter on [DATE], [DATE], and [DATE]; - [MEDICATION NAME] Suppository on [DATE]; and - [MEDICATION NAME] 30 cc on [DATE]. The MAR's and TAR's did not document bowel protocol medications were successively administered as ordered when the resident had no bowel movements between ,[DATE] and [DATE] (8 days). The nursing progress note dated [DATE] document the resident's abdomen was distended and an as needed suppository was given along with [MEDICATION NAME] with results pending. The Bowel Elimination Record documented the resident was incontinent of bowels on [DATE] at 9:00 PM and [DATE] at 10:53 AM. The nursing progress note dated [DATE] at 2:01 PM, documented the resident was not feeling well, had difficulty with speech, the belly was distended, the resident was very drowsy and had as needed Milk of Magnesia. The note documented a urine was obtained for analysis and culture. The untimed nurse practitioner's (NP) progress note dated [DATE] documented the resident was seen for possible mental status changes. The note documented the resident did not feel well and could not specify what was bothering her. The abdomen was slightly firm with hypoactive bowel sounds. The plan was to do a urine culture. The nursing progress note, dated [DATE] at 4:52 PM, documented the resident was slow to respond, was not able to express thoughts and stared at staff. The abdomen was large and distended with stool felt in rectum. The nursing progress note, dated [DATE] at 11:51 PM, documented the registered nurse (RN) was notified the resident had a temperature of 101.3 F, the abdomen was assessed and was found to be very full and distended, with hypoactive bowel sounds. The note documented a digital exam was performed and stool was found in the rectum clay-like in texture. The resident had difficulty responding to questions, skin was hot to touch. The Bowel Elimination Record documented the resident was incontinent of bowels on [DATE] at 5 PM. The nursing progress note dated [DATE] at 4:52 AM, documented the resident received as needed [MEDICATION NAME] with a follow up suppository. The nursing progress note dated [DATE] at 2:55 PM documented a flat plate abdominal x-ray was done with no result. The note documented the resident's belly was hard and distended and had an enema with no result, the urine was still pending and the resident remained on an antibiotic. The nursing progress note, dated [DATE] at 3:48 PM, documented the resident was assessed after the charge nurse reported the abdomen was distended and firm and the resident had not had a bowel movement for at least 4 days. The nursing note documented the resident's bowel record was reviewed; the resident had a medium bowel movement recorded the previous two days. A soap suds enema was ordered and was not found in building. The note documented the order was changed to a mineral oil Fleets which was administered. The nursing progress note dated [DATE] at 9:16 PM, documented the urine and x-ray results were pending, the resident had in addition to the mineral oil enema received Magnesium [MEDICATION NAME] and had not had any results. The note documented the abdomen remained hard and distended and there was a new order for [MEDICATION NAME] (treats constipation) 24 micrograms (mcg) twice daily which would not be available until the next day. The ,[DATE] MAR and TAR documented on [DATE], the resident received a [MEDICATION NAME] suppository, Magnesium [MEDICATION NAME] solution 150 ml, Milk of Magnesia 10 ml, and [MEDICATION NAME] solution 30 ml. The nursing progress note dated [DATE] at 12:54 AM, documented verbal x-ray results were received suggesting fecal impaction. The physician was notified and an order was received to send to the emergency room . The NP's progress note dated [DATE] documented the resident was seen for constipation. The note documented nursing staff reported the resident had been having abdominal distention and discomfort for a few days and had no bowel movement despite multiple bowel medications and it was her fourth day without a bowel movement. The note documented the resident had left the facility at 2 AM after abdominal x-ray results showed the suggestion of a fecal impaction. The comprehensive care plan (CCP) updated [DATE] did not address constipation. The Readmission history and physical examination [REDACTED]. The Computed Tomography (CT) exam of the abdomen showed severe rectal and sigmoid impaction (severe constipation). The resident had a general surgery consult with aggressive measures considered including surgery and the decision for conservative measures was made. The resident required a sigmoidoscopy, a rectal tube, and multiple medications for management. During an interview with licensed practical nurse (LPN) #18 on [DATE] at 10:10 AM, she stated she did not know the resident had a problem, or that he did not have a bowel movement between ,[DATE] and [DATE]. She stated on [DATE], the resident was distended and multiple medications were given which did not work. During an interview with registered nurse (RN) Manager #54 on [DATE] at 10:33 AM, she stated the resident had decreased intake due to tooth pain and oral surgery in ,[DATE]. She said they were trying to push fluids, and there was an intense bowel program. She stated she believed the resident was at 3 days without a bowel movement and staff might had not documented all bowel movements. During an interview with nurse practitioner (NP) #13 on [DATE] at 11:12 PM, she stated she saw the resident when she was not feeling well and the resident had no specific complaint. She stated she was not aware of the length of time the resident was without a bowel movement. NP #13 stated there was a bowel regime and when residents had chronic constipation it would be on report. During an interview with registered nurse (RN) #15 on [DATE] at 10:05 AM, she stated she worked consistently on the resident's unit. She stated the certified nurse aides (CNAs) documented in the computer system when a resident had a bowel movement and also documented in a log book. The information was reviewed by the Unit Manager who let staff know when there was a problem. She stated she did not know the resident had a problem until this week. During an interview with the Director of Nursing (DON) on [DATE] at 10:45 AM she stated she had just pulled a bowel report and determined they were not tracking bowels every day. During an interview with the Medical Director on [DATE] at 12:30 PM, she stated she was not aware the resident had a problem or that the ordered interventions were not followed. The Medical Director stated she first learned there was a problem when the resident was distended and had pain. 2) MONITORING ANTICOAGULANT THERAPY: The facility's policy Preparing Order Sets upon Admission/Processing of New Orders was last revised in [DATE]. The policy documented the admitting RN (registered nurse) would utilize the Discharge Summary; Medication Reconciliation List; Facility Formulary and referring facility Medication Record to create an Admission Order Set to be reviewed with the attending or on-call physician. Documented to be included in the initial complete order set was initial lab studies that were to be completed. The policy also documented it was the responsibility of each trained licensed nurse to check for new orders entered requiring processing or verification of accuracy r/t (related to) scheduling at the beginning of their assigned shift, periodically throughout the shift span, and prior to leaving at the end of the assigned shift. The facility's policy Care of Residents on Anticoagulant Therapy/with Bleeding Disorders, was revised in [DATE] and documented it superseded and replaced the [MEDICATION NAME] Therapy Policy. The policy, under the title Assessments, documented staff were to obtain baseline lab data as per physician or nurse practitioner order; and PT/INR results as ordered for residents on [MEDICATION NAME] ([MEDICATION NAME]) therapy, but at least every 30 days. The policy specified the registered nurse was to record results in the EMR (electronic medical record) in a PT/INR Progress Note. Resident #17 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, limited assistance was required with activities of daily living (ADLs) and he did not receive anticoagulant medications (blood thinners). The last physician progress notes [REDACTED]. The note documented the resident had chronic leg [MEDICAL CONDITION]; there was no apparent care plan; and the resident needed a venous Doppler study (an ultrasound used to search for blood clots) to rule out a [MEDICAL CONDITION]. A venous Doppler study was performed on [DATE] at 10:57 AM on both legs and the study documented the resident had two acute [MEDICAL CONDITION] in the left leg. A nursing progress note, dated [DATE] at 1:01 PM, documented the physician was called with the results of the Doppler. The physician advised nursing to speak with the physician from [MEDICAL TREATMENT] to determine treatment. A nursing progress note, dated [DATE] at 3:08 PM, documented the resident was admitted to the hospital directly from [MEDICAL TREATMENT]. The hospital nurse practitioner (NP) discharge summary, dated [DATE] at 12:31 PM, documented the resident was hospitalized from ,[DATE] to [DATE] for a [MEDICAL CONDITION] and was started on intravenous [MEDICATION NAME] (a blood thinner) in the hospital and [MEDICATION NAME] (oral blood thinner). The summary documented No [MEDICATION NAME] ordered for tonight, ,[DATE], as the INR (International Normalized Ratio, a test used to determine clotting tendency of blood) was 3.06 (therapeutic range for a [MEDICAL CONDITION] is 2XXX,[DATE].0). The summary documented the PT ([MEDICATION NAME] time-determines clotting tendency of blood) and INR dosage for [MEDICATION NAME] was ordered for tomorrow at nursing facility, with instructions to call for [MEDICATION NAME] dose. The hospital discharge instructions dated [DATE], documented to check the PT/INR tomorrow and call for [MEDICATION NAME] dose. A physician order, dated [DATE] at 5:20 PM, documented a lab order for PT/INR the following morning and to call the physician for [MEDICATION NAME] dosing. The nursing admission summary, dated [DATE], documented the resident was readmitted to the facility with a [DIAGNOSES REDACTED]. There was no documentation a PT/INR was scheduled for the following morning. The [DATE] medication administration record (MAR) did not document an order for [REDACTED]. The MDS, dated [DATE], documented the resident did not receive anticoagulant medications. A nursing note, dated [DATE] at 11:28 PM, documented the resident stated he could not breath and was coached to slow down his breathing. The resident continued to state he could not breath. The note documented the resident's oxygen level was 59% (normal range is ,[DATE]%) and he was given 2 liters of oxygen. The note documented the oxygen was later reduced to 1.5 liters; his oxygen level was 67% with finger tips blue and feet swollen; and the physician was called to advise on resident's condition. A nursing progress note, dated [DATE] at 11:52 PM, documented a code blue ([MEDICAL CONDITION]) was called at 11:35 PM. Cardiopulmonary resuscitation was started and 911 was called. The ambulance arrived at 11:48 PM. The resident was transported to the hospital. There were no medical staff notes documented in the resident's medical record between the resident's re-admission on [DATE] and discharge on [DATE]. A nursing note progress, dated [DATE] at 5:29 AM, documented the NP from the hospital called to confirm the resident was not currently taking [MEDICATION NAME]. The MAR and physician orders [REDACTED]. The hospital laboratory report dated [DATE], documented an INR of 1.25 (normal therapeutic range 2.0 - 3.0). Hospital records, dated [DATE] at 12:21 AM documented the resident left the nursing home in full arrest and had CPR for 20 minutes in addition to defibrillation and medications, including 3 doses of [MEDICATION NAME]. At 1:32 AM, the hospital's history and physical documented resident had asystole arrest (flatline) that was suspected to be respiratory related. The resident had a known [MEDICAL CONDITION]; a subtherapeutic INR value; and had not been given [MEDICATION NAME] since his hospitalization on [DATE]. The resident was on a ventilator and unresponsive to any stimuli At 10:15 AM, results of a CT scan of the brain documented suggesting [MEDICAL CONDITIONS] diffuse cerebral [MEDICAL CONDITION]. The facility's incident report, dated [DATE], documented the resident did not receive [MEDICATION NAME] when the resident was readmitted on [DATE]. The report documented the registered nurse (RN) who transcribed the physician order, for the resident's blood work (PT/INR) to be drawn the following day, did not notify anyone of the order. The report documented the initial order was not checked for accuracy by a second licensed staff member. During an interview with the Director of Nursing (DON) on [DATE] at 4:00 PM, she stated when a lab was ordered, a requisition was to be printed and placed in the new order book; the ward clerk was to check the book and put the order into the computer. The DON stated this practice was now changed after Resident #17 did not have his lab work completed when readmitted on [DATE]. She stated the current process specified the admitting nurse was to enter the lab orders into the computer for the labs to be drawn the following day before the ward clerk reported to work. She stated there was no policy for new admission orders [REDACTED]. The DON stated the night RN Supervisor received a list of all new admissions with a copy of the admission packet from the hospital and was responsible for checking all new admission orders [REDACTED] During an interview with RN #22 Manager on [DATE] at 9:34 AM, she stated the night Supervisor had an audit tool to do a third check of physician orders. She said there was supposed to be a worksheet that accompanied the admission, but it had not been used in a long time. RN #22 Manager stated she was confused with the policy. She stated she was aware Resident #17 did not have a PT/INR drawn. She stated she knew the PT/INR was not documented in the admission progress note or the 24 hour report when the resident was admitted . During an interview with RN #10 on [DATE] at 3:10 PM, she stated she was primarily responsible for admissions and readmissions to the facility. She stated she did not complete a PT/INR progress note linked to her admission note for Resident #17, and did not address it on the 24 hour report. During an interview with the physician on [DATE] at 11:00 AM, he stated he would expect any resident treated for [REDACTED]. He stated he was aware Resident #17 did not have his PT/INR drawn. He stated he could not comment further as he did not currently have the medical record available to review. 3) SURGICAL WOUNDS Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident was cognitively intact. The [DATE] in house wound care assessment documented: - site 1, the left upper thigh wound, measured 4.5 centimeters (cm) x 2.7 cm x <0.2 cm, with 10% eschar (necrotic tissue); - site 2, the left lower leg wound, measured 8 cm x 3 cm x 0.2 cm, with 20% tendon exposed, 20% scabbed area, and 40% slough (necrotic tissue); and - recommendations were to apply Santyl (wound treatment) to the left lower leg wound and cover with Vaseline gauze and to apply [MEDICATION NAME] (topical antibiotic) to the left upper thigh wound and cover with Vaseline gauze. A second form, consultation notes, completed by the same provider as the [DATE] wound care assessment, documented recommendations were to discontinue the [MEDICATION NAME] for the left lower leg wound and apply Santyl and cover with Vaseline gauze. That form did not document recommendations for the upper thigh wound. The Medication Administration Record (MAR) documented on [DATE], the [MEDICATION NAME] was discontinued for both the upper thigh and lower leg wounds. The Treatment Administration Record (TAR) documented on [DATE], the recommendations for the lower leg wound were implemented as recommended (Santyl and Vaseline gauze). The [DATE] and [DATE] wound care assessments documented a plan to continue with prior treatments of Santyl and Vaseline gauze to the lower leg wound and [MEDICATION NAME] to the thigh wound. The ,[DATE] and ,[DATE] MAR and TAR did not document the [MEDICATION NAME] was ordered following either wound care assessment. The [DATE] wound care assessment documented the resident had a third wound, site 3, which was on the left upper leg below site 1. Recommendations included Xeroform gauze to all wounds to cover with ABD pads. The ,[DATE] TAR documented the treatments were administered as recommended starting on [DATE]. The [DATE] wound care assessment documented; - the resident refused assessments of sites 1 and 3; - site 2, the left lower leg wound, measured 6 cm x 2.5 cm, with 80% slough; and - recommendations included discontinuing the Xeroform gauze to the left lower leg and applying Santyl and covering with Vaseline gauze. The ,[DATE] MAR and TAR did not document Santyl was ordered between [DATE] and [DATE] for the left lower leg wound. On [DATE] the resident saw the ear nose and throat (ENT) specialist who performed the graft to repair his jaw bone. The ENT examined the resident's leg wounds and recommended wet to dry dressings to be done every day. The ,[DATE] TAR did not document the wet to dry dressings were ordered. On [DATE], the resident went to an outside Wound Clinic and the note documented they applied Coban 2 Lite compression wraps to the leg and they were to be left on for 1 week and removed at the Wound Clinic in a week. On [DATE], the ENT documented the resident's leg wounds were examined, and daily [MEDICATION NAME] was recommended. There was no documented evidence the ENT was informed of the Wound Clinic's recommendations to keep the wraps on for 1 week. The ,[DATE] TAR documented the [MEDICATION NAME] was ordered as recommended following the [DATE] appointment. On [DATE] the resident saw ENT and ENT documented to follow wound care recommendations from the Wound Clinic. On [DATE] at 4:20 PM, registered nurse (RN) Manager #47 stated in an interview, the nurse practitioner (NP) would had been told of recommendations from the in-house wound care, Wound Clinic, and the ENT, and would have decided which recommendations to follow. During an interview on [DATE] at 5:15 with RN Manager #51, she stated she was the resident's RN Manager from ,[DATE]-,[DATE] and during that time she felt it was confusing because the resident was seeing multiple people at one time for wound recommendations. She stated the NP would have made decisions and ordered what she felt was appropriate. On [DATE] at 9:55 AM, the NP stated in an interview, - in house wound care assessment were done by a nurse who left the facility in ,[DATE]; - she came from out of state and left her recommendations at the facility; - the [MEDICATION NAME] in ,[DATE] and part of ,[DATE] was missed and not ordered as planned; - in ,[DATE], ENT recommended wet to dry dressings and she did not order them as she did not agree with the recommendation; - she discussed the resident's care with the physician and either herself or nursing spoke with ENT regarding the resident seeing 2 providers at once for wound care; - on [DATE] when the wraps removed by ENT, she expected the 2 consultants to have communicated with each other (ENT and Wound Clinic) so that did not occur. 4) WOUND V.A.C (vacuum assisted closure) and VASCULAR CARE: Resident #3 had [DIAGNOSES REDACTED]. The surgical discharge summary dated [DATE], documented the resident had a right lower leg femoral (artery) embolectomy (blood clot removal) and fasciotomy (surgical procedure to relieve pressure). The summary documented the Wound V.A.C dressing was to be changed three times weekly and if Wound V.A.C therapy failed, wet to dry normal saline dressing changes should be started twice daily and the vascular surgeon notified. The note documented that ace wraps to both lower legs should be continued. The admission history and physical dated [DATE], documented the resident was admitted to the facility for rehabilitation. The plan was for wound care with a Wound V.A.C with instructions from the vascular surgeon. The comprehensive care plan (CCP) dated [DATE], documented the resident had potential skin impairment and pain related to Wound V.A.C. Interventions included good nutrition, facility protocols followed for treatment of [REDACTED]. Physician orders [REDACTED]. - Ace wraps were to be applied to both lower legs for gentle compression every day; and - right lower leg Wound V.A.C dressing changes were to be completed three times weekly on Monday, Wednesday and Friday; and - when unable to get the Wound V.A.C to function, normal saline wet to dry dressings were to be completed twice daily and the RN was to be notified. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact, a surgical wound was present, and extensive assistance was required with activities of daily living (ADLs). The licensed practical nurse's (LPN) progress note dated [DATE] at 11:34 AM, documented the Wound V.A.C dressing change was completed without issues, there was no drainage or odor, and the resident had no pain. The registered nurse (RN) progress note dated [DATE] at 9:39 PM, documented the resident complained of pain at the Wound V.A.C site and the dressing was assessed as too large in circumference and depth causing extra pressure on the wound. The note documented the dressing was reapplied and the resident denied pain. Physician orders [REDACTED].A.C and place wet to dry dressing until seen by the vascular surgeon. When the resident was observed on [DATE] at 11:00 AM, she was seated in a wheelchair in her room and wearing shorts. The resident did not have Ace wraps on her legs at that time. The medial side of her right lower extremity was observed to have multiple, long scabs. On [DATE] at 4:15 PM, the resident was observed being pushed in her wheelchair by a family member near the elevators. The resident wore low socks and shoes; no Ace wraps were applied to the resident's lower legs. On [DATE], the surveyor reviewed the resident's [DATE] medication administration record (MAR). The MAR documented that from ,[DATE] to [DATE] (16 days) the resident had: - daily Ace wraps to both lower legs applied on 4 of 16 days; and - the Wound V.A.C dressing change completed on 1 day (ordered 3 times weekly); and - a wet to dry dressing change completed on 6 occasions (ordered twice daily when the Wound V.A.C was not functional). The resident's ,[DATE] Treatment Administration Record (TAR) documented the resident's pain level was to be monitored every shift starting on [DATE] at 11 PM. - The TAR contained no documentation the resident's pain was monitored on the day shift on ,[DATE], ,[DATE], ,[DATE], ,[DATE] - ,[DATE], ,[DATE] and [DATE]. When the resident's pain level was monitored on the remaining 8 days, 0 was documented for the pain level. - The TAR contained no documentation the resident's pain was monitored on the evening shift from ,[DATE] - ,[DATE], ,[DATE], ,[DATE] - ,[DATE], and [DATE]. When the resident's pain level was monitored on the remaining 4 days, 0 was documented for the pain level. - The TAR for the night shift documented the resident's pain was monitored every night from ,[DATE] - [DATE]. The resident's pain level was 0 for 12 nights and rated 6 on ,[DATE]; rated 5 on ,[DATE]; and rated 7 on ,[DATE], ,[DATE], ,[DATE] and [DATE]. The medical record did not document an RN assessment when the Wound V.A.C dressing changes were not completed and did not document the vascular surgeon was notified when wet to dry dressing were applied instead of the Wound V.A.C. The facility's Wound V.A.C policy last updated ,[DATE] documented that LPNs may only observe the integrity of the system. On [DATE] at 4:15 PM, LPN #45 was interviewed and stated he worked the day shift on [DATE], he did not complete the resident's Wound V.A.C dressing change, and did not sign the MAR for it. He stated he was not trained on the Wound V.A.C and a LPN was not allowed to complete Wound V.A.C dressing changes at this facility. He stated he notified RN #46 the dressing change was due and she stated she would take care of it. He stated he did not know why the resident had leg wraps, he did not recall applying them on [DATE], was not sure why he had not signed the MAR, and was not sure if he notified the RN. On [DATE] at 5:15 PM, RN Manager #47 Manager was interviewed and stated only RNs completed Wound V.A.C dressing changes and it should be documented in the MAR and progress notes. She stated she was not sure why signatures for the Wound V.A.C dressing changes were missing on the MAR and thought RN #46 had completed them because they had spoken about the dressing changes frequently in ,[DATE]. On [DATE] at 8:50 AM, LPN #48 was interviewed and stated she was an agency nurse, had only worked at the facility for about 2 weeks, and completed the resident's Wound V.A.C dressing change on [DATE]. She stated she had no issues when she c

Based on observations, interviews and record review conducted during the standard and abbreviated survey (#NY 228), it was determined for 3 of 9 residents (Residents #11, 17, and 25) reviewed for pressure ulcers, the facility did not ensure necessary treatment and services were provided to promote healing. Specifically, Resident #11 did not receive pressure ulcer treatment as ordered by the physician; Resident #17 had a change in status of a pressure ulcer that was not communicated to, or assessed by a qualified professional (physician, registered nurse), in a timely manner, and Resident #25's pressure ulcer was not assessed by a qualified professional in a timely manner. This resulted in actual harm to Resident #17, and no actual harm with potential for more than minimal harm that is not immediate jeopardy, for Residents #11 and 25. Findings include: 1) Resident #17 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated [DATE], documented the resident's cognitive status was severely impaired. The resident required supervision for bed mobility; limited assistance for transferring, ambulation, and eating; and extensive assistance for dressing, toileting, hygiene, and bathing. The MDS recorded the resident had no skin impairment, and was at risk for pressure ulcer development. The physician progress notes [REDACTED]. The Wound Record Tracking Sheet, dated [DATE] at 2:03 PM, documented the resident's coccyx pressure ulcer was a Stage II measuring 4.0 cm x 2.0 cm, and was "clean larger." The sheet documented [MEDICATION NAME] Absorbant was continued. The Wound Care registered nurse (RN) progress note, dated [DATE], documented the resident had an unstageable "wound" on the left sacrum measuring 4.0 cm x 2.0 cm, the center was "boggy", with 100% slough (moist, dead tissue), and dark necrotic (dead) tissue in the center. The note documented the RN Manager would notify the physician. A physician order, dated [DATE], documented to cleanse the resident's left sacrum pressure ulcer with normal saline, pat dry, apply [MEDICATION NAME] (sterile ointment that removes dead tissue) and [MEDICATION NAME] (type of sterile dressing) every day, and as needed. The Wound Record Tracking Sheet, dated [DATE] at 2:03 PM, documented the resident's coccyx pressure ulcer was unstageable measuring 4.0 cm x 2.0 cm, with a scant amount of exudate, and 75% slough and 25% granulation tissue. The tracking sheet also documented the pressure ulcer was larger, and worse, with slough, and a small amount of eschar present. The treatment was changed to [MEDICATION NAME] and a dry sterile dressing daily. On [DATE] at 12 PM, the RN Manager progress note documented the resident had a Stage III pressure ulcer on her right sacrum. The RN documented the physician was "consulted about the wound", and there was no change in the daily treatment. There was no documented evidence, in the resident's medical record, of a physician signature for the order to change the pressure ulcer treatment from [MEDICATION NAME] absorbent to [MEDICATION NAME] dated [DATE]. On [DATE] at 12:30 PM, the attending physician was interviewed and stated she was not notified of, or consulted regarding, the resident's pressure ulcer progressing from a Stage II to a Stage III. The physician stated she did not order the treatment change from [MEDICATION NAME] Absorbant to [MEDICATION NAME] on [DATE]. There was no documentation in the resident's medical record the resident's coccyx pressure ulcer was assessed, or the treatment evaluated by a qualified person, from [DATE] until [DATE]. The Wound Record Tracking Sheet, dated [DATE] at 10:43 AM, documented the resident's coccyx pressure ulcer was unstageable, measuring 6 cm x 4 cm x 0.5 cm with a scant amount of serosanguinous (blood and serum) drainage, and was covered with eschar (hard, dark, dead tissue). The treatment was to apply [MEDICATION NAME] daily and as needed. An EZ air mattress (pressure relieving air mattress) was placed on the bed. There was no documentation, in the resident's medical record, the physician was notified the resident's coccyx pressure was larger and covered with eschar. The RN Manager progress note, dated [DATE] at 11:04 AM, documented she would discuss care for the resident at the wound clinic with the resident's family. The MDS assessment, dated [DATE], documented the resident was totally dependent on staff for all activities of daily living (ADLs) and had an unstageable pressure ulcer with eschar that measured 6.0 cm x 4.0 cm x 0.5 cm. The ,[DATE] treatment administration record (TAR) documented the resident's coccyx pressure was treated daily with [MEDICATION NAME] from ,[DATE] - [DATE]. There was no documentation in the resident's medical record the physician was notified of the resident's worsening coccyx pressure ulcer until [DATE]. The physician's orders [REDACTED]. The nursing progress note, dated [DATE] documented the resident was to be seen at the wound clinic on [DATE]. The Wound Record Tracking Sheet dated [DATE] documented the resident's unstageable coccyx pressure ulcer was larger, measuring 9.5 cm x 6.5 cm, with 100% dry, dark eschar, and a foul odor. The treatment remained [MEDICATION NAME] with a dry sterile dressing daily, and an appointment at the wound care clinic. The nursing progress note, dated [DATE] at 6:43 AM, documented the resident's coccyx pressure ulcer continued to look worse, and had foul smelling drainage. The resident's temperature was 100.4 degrees Fahrenheit (F) and Tylenol 500 mg was given. The physician progress notes [REDACTED]. The physician documented "when I last saw her on [DATE] she had a clean Stage II pressure ulcer of the left buttock area which was reported by nursing to be not worse, and with no signs or symptoms of infection." The physician documented upon exam the resident had a temperature of 100.4 degrees F, she appeared pale, and her eyes were glazed. The coccyx pressure ulcer was foul smelling, with black eschar, impression was a Stage IV/indeterminate gangrenous pressure ulcer with low grade fever. The physician documented the resident would be transferred to the hospital for "full cultures", surgical debridement (removal of dead tissue), and intravenous (IV) antibiotics. The resident expired at the hospital on [DATE]. During an interview the current RN Manager, on [DATE] at 10:30 AM, stated she did not normally manage that unit and was covering the day the resident was sent to the hospital. She stated she saw the resident's pressure ulcer in [DATE] when it was a tiny abrasion, and did not see it again until the day before the resident went to the hospital. The RN Manager stated that weekly skin checks were done by the LPN who informed the RN of what was observed. Measurements of resident pressure ulcers were done weekly, by the RN Manager, and reported to the skin care team. She stated the resident's RN Manager was no longer employed at the facility. During an interview with the Wound Care RN on [DATE] at 10:55 AM, she stated the wound care team looked at wounds once a month. The wound care team included the DON, the nurse Manager, the wound care nurse, an RD, and the VP of Support Services (also an RD). The Wound Care RN stated the last time she saw the resident's pressure ulcer was on [DATE]. She stated at that time the RN Manager was going to call the physician to obtain orders for [MEDICATION NAME], and an appointment for the wound care center. She stated skin care rounds were made by the team monthly. The status of resident pressure ulcers were were reviewed weekly from the skin conditions report that each unit RN Manager completed and submitted to the Wound Care RN. She stated the resident's RN Manager had been behind on her weekly skin condition reports, and therefore the skin team did not know the resident's pressure ulcer was getting worse. The Wound Care RN stated if she knew the resident's pressure ulcer was deteriorating, she would have done something quicker. She stated the DON and VP of Support Services were notified the weekly skin sheets were not received. During an interview with the attending physician, Medical Director, on [DATE] at 12:30 PM, she stated when a resident developed a pressure ulcer she expected to be notified for a treatment order. She stated she would not necessarily examine a Stage I or II pressure ulcer right away, but would examine it on her routine visit. She stated she would expect to be notified immediately if a Stage II pressure ulcer was not improving within 2 weeks of treatment or, if it progressed to a Stage III, IV, or unstageable pressure ulcer, and of any worsening condition. The physician stated she was "shocked" when she was notified about the resident's deteriorating pressure ulcer. She stated she would have looked at it immediately, if she had been notified, when it progressed from a Stage II to an unstageable pressure ulcer. She stated she was not notified the pressure ulcer deteriorated and did not order the change of treatment to [MEDICATION NAME]. When she was notified of the status of the resident's pressure ulcer, she examined the resident and sent her to the hospital. 2) Resident #11 had [DIAGNOSES REDACTED]. The wound care clinic note, dated [DATE] at 11:30 AM, recommended the resident be on strict bed rest in a flat position on a low air loss mattress with the head of the bed elevated for meals only, and to continue [MEDICATION NAME] (type of wound treatment) application to the wound daily. The Minimum Data Set (MDS) assessment, dated [DATE], documented the resident's cognitive status was severely impaired; he was totally dependent on the staff for transferring, dressing, toileting, and bathing; he required extensive assistance for bed mobility and personal hygiene, and required supervision for eating. He had a Stage II and a Stage IV pressure ulcer present on readmission; treatments included pressure reducing devices for the chair and bed, a turning and positioning program, nutrition or hydration intervention, pressure ulcer care, applications of nonsurgical dressings, and applications of ointments/medications. During a wound care observation on [DATE] at 10:05 AM, the certified nurse aide (CNA) removed the resident's brief. A dressing dated ,[DATE] was observed on the resident's sacrum; there was no dressing covering the ischium. The licensed practical nurse (LPN) removed the dressing from the sacrum, 2 open areas were observed on the sacrum and both areas were covered with yellow tissue. The LPN told the surveyor the site was "excoriation" and was treated with silver [MEDICATION NAME] cream. The open area on the right ischium was observed to be clean with a red base; the bottom edge was whitish in color. The LPN cleansed the pressure ulcer with normal saline flush, inserted [MEDICATION NAME], covered the site with a foam and [MEDICATION NAME] dressing. The sacrum was treated with silver [MEDICATION NAME] cream and covered with an incontinence brief. When asked why there was no dressing on the ischium at the start, the LPN stated the dressing on the sacrum should have been on the ischium. She stated she would report the error. A Wound Care RN note, dated [DATE] at 5:08 PM, documented she performed a full body assessment and to refer to the wound tracking sheets for the information on the pressure ulcer on the right ischium and the new right and left sacral pressure ulcers. A Wound Record Tracking Sheet, dated [DATE], documented a Stage IV pressure ulcer on the right ischium with [DATE] as the date of origin. It documented assessments were done by the Wound Care RN on [DATE], [DATE], and [DATE]. Wound Record Tracking Sheets were initiated on [DATE] at 4:59 PM by the Wound Care RN for new unstageable pressure ulcers on the right and left sacrum. The right sacrum pressure ulcer measured 1.6 cm x 4.3 cm with 80% slough, appeared superficial and was caused by shearing. The left sacrum pressure ulcer was identified as unstageable, measured 4.0 cm x 2.5 cm, was 80% slough, with macerated tissue. Review of the 24 Hour Report for [DATE] and [DATE] revealed no documentation regarding Resident #11. During an interview with the LPN on [DATE] at 9:30 AM, she stated the CNA reported the resident's dressing came off during a shower on the evening of [DATE]. The LPN stated she floated to the unit and did not know the resident or his treatment. She stated she looked at the treatment administration record (TAR) for instructions and was so focused on the type of dressing she had to apply, that she overlooked where it was supposed to be applied. The LPN stated she saw the pressure ulcer on the sacrum and put the dressing there, and did not see the pressure ulcers on the ischium. 3) Resident #25 had [DIAGNOSES REDACTED]. The nursing progress note, dated [DATE] at 12:59 AM, documented the resident had several superficial open areas on her sacrum and buttocks, and [MEDICATION NAME] (a transparent dressing) was applied. The weekly skin condition report for pressure ulcers, dated ,[DATE] to ,[DATE] (no year), documented the resident had unstageable pressure ulcers on both heels and a pressure ulcer on the natal cleft (coccyx). The nursing progress note, dated [DATE] at 7:13 AM, documented 3 intact blisters were found on the the resident's right gluteal fold; No Sting (a skin barrier film) was applied. The note specified they would "monitor" the area. The Minimum Data Set (MDS) assessment, dated [DATE], documented the resident had one Stage II pressure ulcer and one unstageable pressure ulcer, both present on admission. Treatments included pressure reducing devices for the chair and bed; a turning/positioning program; application of nonsurgical dressings, and applications of ointments/medications. The nursing progress note, dated [DATE] at 8:46 AM, documented the resident had 2 pressure ulcers, a Stage II on the right sacrum and an unstageable pressure ulcer dark in color. No location was documented for the unstageable pressure ulcer. Review of the nursing progress notes and the weekly skin reports, dated [DATE] through [DATE] revealed no documented evidence the blisters on the resident's right gluteal fold were assessed and treated or, that the physician was notified. The Wound Care RN note dated [DATE] at 10:56 AM documented the resident had an open area on the right gluteal fold, covered with 20% dark necrotic (dead) tissue on the edge closest to the groin; the rest of the pressure ulcer was covered with slough (moist yellow dead tissue). The wound measured 3.0 cm x 1.0 cm x 0.2 cm, was unstageable, and the nurse practitioner (NP) was notified. The resident's ,[DATE] treatment administration record (TAR) did not document any treatment to be provided to the resident's right gluteal fold. During a care observation on [DATE] at 2:40 PM, the resident was put to bed by 2 certified nurse aides (CNAs) using a mechanical lift. The resident had been incontinent of urine and stool, and her pants were visibly wet. The resident was cleansed, [MEDICATION NAME] cream (barrier cream) was applied to her buttocks, and an open area was observed on the resident's right gluteal fold. The area was very red at one end, with hard, black tissue at the other end; yellowish tissue covered most of the pressure ulcer. No treatment was used on this area. The CNA told the surveyor that the open area at the resident's gluteal fold was new and said she told the nurse about it earlier in the day. The resident's comprehensive care plan (CCP), dated [DATE], did not address the skin impairment on the right gluteal fold. During a wound care observation on [DATE] at 11:40 AM, the resident had stool under the transparent dressing on her sacrum. There was no dressing on the right gluteal fold pressure ulcer. The licensed practical nurse (LPN) came in and was observed to provide the prescribed treatments. The LPN flushed the right gluteal fold pressure ulcer with saline, applied Silvadine cream, and covered it with a 4 x 4 inch [MEDICATION NAME] pad (type of sterile dressing). She removed the soiled transparent film dressing from the sacrum. The pressure ulcer was red with a small opening. The LPN cleansed it with a saline flush and covered it with a shaped transparent film dressing. During an interview with the CNA on [DATE] at 1:40 PM, she stated the pressure ulcer on the resident's right gluteal fold started out as a blister. She stated the blister popped and started looking worse around [DATE]. She stated she informed both the medication LPN and the charge LPN. Review of the 24 Hour Report for ,[DATE] and [DATE] revealed no documentation regarding this resident. During an interview with the charge/treatment LPN on [DATE] at 10:05 AM, she stated the resident's right gluteal fold pressure ulcer started as a blister. They were monitoring it and used No-Sting. When the blister broke over the weekend, No-Sting treatment was continued. The LPN stated by [DATE], the area was considerably worse. She stated she called the Wound Care RN, and the Wound Care RN notified the nurse practitioner (NP). During an interview with the NP on [DATE] at 10:10 AM, she stated she was aware the resident had an unstageable ulcer on her right gluteal fold. She stated she did not see it and did not know how it started. She stated the wound care RN called her on [DATE] for a treatment order. She stated the wound care RN called her when wounds became worse and for wounds present on admission. The NP stated she ordered whatever treatment the wound care RN recommended. She stated wounds did not usually change from a Stage II to unstageable in one day but, it could happen. During an interview with the wound care RN on [DATE] at 11:50 AM, she stated she was called to look at the resident's pressure ulcer on [DATE] for the first time. She stated the resident's right gluteal fold was open, irregular, and unstageable, with slough and eschar. She stated she reviewed the nursing progress notes and found the pressure ulcer was documented as a blister on [DATE]. The wound care RN stated this should have been on the 24 hour report but was not. She stated the pressure ulcer could go from a Stage II to unstageable quickly, due to the resident's incontinence. 10NYCRR 415.12 (c)(1)(2)

Based on record review and staff interviews conducted during an abbreviated survey (complaint #NY 757), the facility did not ensure the resident received appropriate treatment and services to prevent urosepsis from developing for 1 (Resident #1) of 5 residents reviewed for urinary tract infections. Specifically, the facility did not ensure a resident who had a history of [REDACTED]. The resident's catheter was removed at the facility on the first day of admission. The resident subsequently developed urosepsis (a secondary infection spread through the blood stream), was hospitalized and died . This resulted in actual harm that is not immediate jeopardy. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission RN (registered nurse) assessment documented on [DATE] that the resident had an indwelling urine catheter. The CCP (comprehensive care plan), dated [DATE] documented the resident was incontinent of bowel and bladder, a barrier cream would be used with AM and PM care, brief would be changed every ,[DATE] hours and pericare would be provided after each episode of incontinence. The facility's admission history and physical was performed by a physician (dated [DATE]). It documented the resident had a"complex" urinary tract infection with hematuria and was treated [MEDICATION NAME](and antibiotic [MEDICATION NAME]) and [MEDICATION NAME] (an antibiotic) with use of a foley catheter while in the hospital from [DATE] to [DATE]. Under the "impression" section of the document, the physician recorded "recurrent urinary tract infection with and without hematuria." The physician orders [REDACTED]." Labs were ordered. The facility's policy titled "Urinary Tract Infections: Prevention and Treatment" documented that according to AMDA/APIC (American Medical Directors Association/Association for Professionals in Infection Control and Epidemiology) standards, a resident has a urinary tract infection if two or more of the following exists: Fever greater than 100 degrees or chills, flack (flank?) or suprapubic pain or tenderness, change in character of urine (odor, sediment, pyuria), worsening of mental or functional status, recent change in catheter, scheduled or unscheduled and urine culture positive growth of greater than 100,000 col/ml. At "J" under the heading of intervention, it is documented if a urinary tract infection is suspected "initial treatment should be ordered for four days. This is the time period for the pending culture results to be made available." A nursing progress note dated [DATE] for 11 PM to 7 AM documented the resident's catheter was removed. In nursing progress notes dated [DATE] for the 7 AM to 3 PM shift and for the 3 PM to 11 PM shift two (one for each shift) LPNs (licensed practical nurses) documented the resident complained of lower back pain and was medicated with Tylenol. It was documented for the day shift that the resident's appetite was poor. The intake and output record for [DATE] documented the resident took in a total of 960 cc's for the 24 hour period. An [DATE] report from Quest Diagnostic Lab (ordered on admission) documented the resident had a BUN of 33 (normal range ,[DATE]) and creatinine of 0.91 (normal range (0XXX,[DATE].22). The intake and output record documented on [DATE] the resident took in a total of 420 cc's for the 24 hour period. In a nursing progress note dated [DATE] the LPN documented the resident complained of "frequent urination...the patient was placed on the bedpan and was unable to void. The patient was placed back in the wheelchair. The patient then stated again that she needs to be toileted and again the patient was dry and unable to void on the bedpan. Will request orders for straight cath (catheterization) for U/A (urinalysis, a test to check for an infection in the urine). The intake and output record documented that on [DATE] the resident took in 690 cc's for the 24 hour period. There is no documented evidence for [DATE] and [DATE] that the physician or Nurse Practitioner were notified of the resident's difficulty voiding on [DATE]. Nursing progress notes dated [DATE] documented the resident was medicated four times in the 24 hour period for back pain. The day shift LPN documented the resident needed constant supervision to prevent her from sliding out of her chair and that she needed something to help keep her upright. The intake and output record for [DATE] documented the resident took in a total of 720 cc's for the 24 hour period. The physician orders [REDACTED].#1 who documented "cath (catheterize) patient for UA and C&S" (urinalysis/culture and sensitivity which are tests to identify if there is an infection). In a nursing progress note dated [DATE] the LPN documented the resident's urine was dark and she was catheterized to obtain urine for testing and had a poor appetite. When the resident was catheterized 350 ccs of urine was drained from the bladder. During the 11 PM to 7 AM shift staff documented the resident was "yelling out off and on, complained of stomach, also requested drink and to have lips moistened several times." In a nursing progress note dated [DATE] for the 3 PM to 11 PM shift the LPN documented the resident continued to complain of lower back pain, was medicated with Tylenol and an order was obtained for a geri-lounge because the resident required frequent repositioning as she was sliding down in her wheelchair. In a nursing progress note dated [DATE] for the 11 PM to 7 AM shift it was documented by staff (no title documented) the resident was restless, anxious and yelled out on and off throughout the shift. The physician orders [REDACTED]. In a nursing progress note dated [DATE] for the 7 AM to 3 PM shift an LPN documented the resident was alert and oriented with confusion and yelled out throughout the shift and had a poor appetite. In a nursing note dated [DATE] for the 7 AM to 3 PM shift it was documented the resident yelled out during the shift and was medicated with Tylenol. In a social service department social history note dated [DATE], it was documented that lately the resident has had an acute drop in her level of interest and amount of energy, had multiple physical complaints, loss of appetite, and weight loss. An [DATE] Quest Diagnostic Lab report documented the residents BUN was 81 and the creatinine was 2.04. The [DATE] physicians orders documented an order at 12:55 PM for Cefixime oral solution 400 mg daily for seven days. At 3 PM an order was written to cancel the Cefixime order and [MEDICATION NAME]([MEDICATION NAME]) solution 250 mg twice a day for seven days. The record does not contain a progress note from a physician or NP for [DATE]. In a nursing progress note dated [DATE], the LPN documented the resident yelled out with increased discomfort and that Tylenol was administered with minimal relief. The NP (nurse practitioner) was notified and provided an order for [REDACTED]. The physician orders [REDACTED]. In a nursing progress note dated [DATE] at 12:30 PM the LPN documented the resident was transferred to the hospital for dehydration. In a Nurse Practitioner Acute Note, dated [DATE] the facility NP #2 documented she ordered [MEDICATION NAME] for the resident's back pain and Cefixime for a urinary tract infection. In an addendum dictated [DATE] for [DATE], NP #2 documented the resident was sent to the hospital after a meeting with the family where comfort care measures were discussed. The resident's labs of BUN 80, Creatinine of 2.0 and Sodium of 159 were documented in this note a she was documented to have dehydration and significant failure to thrive. The antibiotic was stated to be Cipro. The emergency department physician from the local hospital documented in the emergency room record that the resident was in extremis with dehydration with very poor skin turgor, altered mentation, and global weakness. The resident was found to have significant collapse of the left lung with a pneumothorax and later in the day on the 12th the resident was diagnosed with [REDACTED]. The resident was catheterized at the hospital and root beer colored urine was found. Laboratory reports documented the resident's BUN was greater than 140 and creatinine was 3.7 "which is consistent with severe dehydration." The white blood cell count was "quite elevated at 30.6" and a "urinalysis shows 3+ leukocyte esterase with 1252 white blood cells, 64 red blood cells and 2+ budding yeast consistent with a urinary tract infection." The resident received 4 liters of fluid in the emergency department On [DATE] the hospital admitting physician documented in a progress note the resident's [DIAGNOSES REDACTED]. The [DATE] death certificate documented the immediate cause of death was urosepsis which was due to a urinary tract infection. On [DATE] at noon an RN (registered nurse) Unit Manager was interviewed. She stated they rule out everything else before starting antibiotics in order not to impact on antibiotic resistance. She stated if there is blood in the resident's urine, the resident is started on antibiotics while the testing is being performed. She stated that some of the physicians start residents on antibiotics on Friday to avoid an issue occurring over the weekend. On [DATE] an LPN from another unit was interviewed at 12:45 PM. She stated, if a resident has symptoms of a urinary tract infection such as change in color of the urine or a change in urine output, the physicians start the resident on an antibiotic while awaiting the testing results. During interview on [DATE] at 10:30 AM, an LPN stated if the resident has symptoms of a urinary tract infection they are put on a broad spectrum antibiotic until the UA and C&S return. This LPN and four other LPNs from the unit (interviewed on [DATE] at 10 AM, 10:10 AM, 10:20 AM and 10:25 AM) could not recall any specifics about this resident. The DON (Director of Nursing) was interviewed on [DATE] at 11 AM. She stated that the resident had back pain upon admission to the facility and that it was musculo-skeletal in nature with components of depression. She stated staff thought the resident's decline was due to depression so they waited for the urine studies to return before starting an antibiotic. The DON stated the RN (registered nurse) should call the physician if there is a change in frequency of urination, complaints of burning with urination, or a change in the characteristics of the urine. NP #1 was interviewed on [DATE] at 9:45AM. She stated she wrote the order for the UA and C&S and was covering this resident for NP #2. NP #1 stated she usually asks staff what the urine looks like, if the urine smells and about a fever, but she does not recall the conversation. She stated she does not always write a note when ordering a UA C&S and did not write a note on this resident. NP #2 was interviewed on [DATE] at 11:30 AM. She stated when staff call her for UA and C&S orders, she asks a series of questions in order to decide if antibiotics should be ordered. She stated she asks staff if the resident is eating and drinking, if they are dehydrated, if the urine smells or looks bad and if there are any behavioral changes. She stated if any of these conditions exist, she starts the resident on Bactrim [MEDICATION NAME] awaiting the UA and C& S results. The resident's facility physician (who is also the facility Medical Director) was interviewed via telephone on [DATE] at 10:15 AM and in person on [DATE] at 9 AM. She stated the resident had a history of [REDACTED]. She stated that she cannot explain the root beer colored urine found in the emergency department because the laboratory urinalysis done on [DATE] documented the urine was clear. In addition, the facility staff documented the resident's urine was clear on [DATE] (the same day the hospital got root beer colored urine). In summary, the facility failed to; -obtain orders for a UA and C&S and to provide the resident antibiotics in a timely fashion when on [DATE] she had a difficulty voiding, complained of urgency and recently had a urine catheter removed -ensure the resident was examined by a medical provider when she had a change in condition, and - recognize the resident had a decline in her clinical status NYCRR 415.12(d)(2) Based on medical record review, observation and staff interviews, it was determined that the Administrator failed to ensure that the facility was administered in a manner that enables resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident reviewed during the extended recertification survey. Specifically, the Administrator failed to ensure that the facility had a system in place that accurately identified the residents resuscitative status for 3(#s 11, 22 and 82) of 109 residents . Additionally, the facility failed to effectively educate the staff on how to identify the advanced directive status of the residents. Eleven staff members were unable to accurately verbalize the system of blue dots on the door frame, spine of chart and the "blue book". This had the potential to effect all of the residents residing in the facility. This resulted in Immediate Jeopardy and Substandard Quality of Care to the health and safety of residents. The findings were as follows: (see F 309- IJ /SQC and F 520-IJ): During interview on [DATE] at 4:40pm, Licensed Practical Nurse (LPN) #10 stated she had been trained by the facility on how to identify advance directives. LPN #10 stated until last night, she would check the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' advance directives. During interview on [DATE] at 2:00 pm, the Inservice Coordinator responsible for all staff education stated she has no written curriculum or post test for educating staff about advance directives, and she does not conduct mock CPR drills with the staff. During interview on [DATE] at 4:20pm, the Director of Nursing (DON), who was also the acting administrator, stated staff should use the quickest means available to determine resident's advance directives. The DON also stated staff should use the blue book, blue dots, or medical orders for life sustaining treatment (MOLST) form to determine the resident's code status. During interview on [DATE] at 11:30am, the supervising administrator (SA) stated he was unaware of any discrepancies with the MOLST forms. The SA also stated he was surprised licensed staff would check the MAR, instead of the blue book or MOLST forms. The SA agreed there was a problem with the identification of advance directives. During interview on [DATE] at 11:15am the medical director stated typically, any policies affecting medical care are reviewed by the medical director and nursing staff. The medical director also stated he collaborates with the Inservice Coordinator and the Director of Quality Assurance to review policies when they are presented to him. 10NYCRR 415.26 - There was a cracking noise coming from an elm tree (with a visible vertical split down the trunk) located on the left side front lawn between the building and sidewalk visitor parking area. Documentation was produced from a local tree service (dated ,[DATE] and ,[DATE]) confirming assesment/stabilization of the tree. Facility staff stated two (dead) trees in the same area had been assessed, however plans to cut/remove had not yet been finalized. (RS) DIRECTED CORRECTIVE ACTION: Submit written documentation from a qualified service company verifying the inspection/assesment of the above-cited damaged and dead trees, to include the immediate measures to alleviate any/all potential hazards to the building and/or outside walkways.

Based on staff interviews and record reviews conducted during the abbreviated survey (#NY 080), it was determined the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 sampled resident (Resident #1) reviewed for a change in status. Specifically, the facility did not ensure Resident #1 received care in a timely manner related to the deterioration of her left lower extremity, including its lack of circulation. This resulted in actual harm that is not immediate jeopardy. Findings Include: Resident #1 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. The resident ' s " Pain History and Assessment " , dated [DATE] documented the resident experienced pain " due to left heel ulcer " described as " aching and throbbing " when her left foot was touched or moved. The assessment did not include a description of the foot. Review of nurses notes, dated [DATE] revealed nursing documented the resident refused medications. There was no documented nursing assessment regarding the status of the resident ' s left foot for this date. A nursing progress note, dated [DATE] at 9:30 PM, documented a " new order received to continue treatment to left heel " with [MEDICATION NAME] and Kling with everyday changes for 15 days. There was no documented nursing assessment of the resident ' s left foot for this date. CNA #1 was interviewed (on [DATE] at 12:45PM) and stated when he performed morning care for the resident on [DATE], he noticed the resident ' s foot was blue and informed the nurse. CNA #1 stated he elevated the resident ' s foot with 2 pillows and the color returned to normal. The CNA stated he informed the licensed practical nurse (LPN) #3 of his observations. The CNA stated he was off duty [DATE] through [DATE]. Review of nursing notes, dated [DATE], revealed nursing documented the resident refused medications. There was no documentation in these nursing notes regarding the resident ' s foot. There were no nursing notes documented on [DATE] or [DATE] in the resident ' s medical record. The resident ' s [DATE] MDS assessment documented the resident ' s activities of daily living (ADLs), related to transferring and hygiene, declined from the [DATE] MDS and the resident now required " total " assistance. The [DATE] MDS documented the resident continued to have a Stage III " pressure " ulcer, and " foot problems " . When CNA #2 was interviewed (on [DATE] at 1:00PM), she stated she saw the resident on [DATE]. She said the resident ' s mid calf down to her toes was " purple " , " even after elevating the foot, the color remained purple. " CNA #2 stated she told LPN #2, who said she already spoke with NP #1. The next LPN nursing note was dated [DATE] at 12 PM and documented the resident ' s left lower extremity was " very cold to the touch, bluish in color-poor circulation. " The note specified " color does return slowly back to normal. Will have NP assess. " Review of the resident ' s medical record revealed there was no documentation from the NP #1 or NP #2 on [DATE] that specified an NP saw the resident on that date. The registered nurse (RN) Manager was interviewed (on [DATE] at 11:00 AM.) She stated when she assessed the resident on [DATE], the resident ' s heel was a light purple, " but the wound itself looked fine. " She stated NP #1 looked at the resident ' s foot on that date, and " thought the change in condition was from [MEDICAL CONDITION]. " The surveyor interviewed NP #1 (on [DATE] at 12:30 PM) who stated she did not remember seeing the resident on [DATE]. The RN Manager was asked to join the interview with NP #1. The RN Manager stated NP #1 assessed the resident on [DATE] and said LPN #2 told her that NP #1 saw the resident on [DATE]. The surveyor conducted a telephone interview with LPN #2 (on [DATE] at 11:45 AM) regarding the status of the resident ' s left lower leg and foot from [DATE] to [DATE]. LPN #2 stated " it only started with the resident ' s toes. " The LPN was asked if the attending physician saw the resident. She stated she did not know why the physician did not assess the resident when he did rounds with the RN Manager on [DATE]. LPN #2 stated she thought NP #1 saw the resident more than once " that week " , and said the NP told her the resident had [MEDICAL CONDITION] and staff should try to elevate the resident ' s leg as much as possible. On [DATE] at 10AM, an RN note documented the resident ' s skin assessment was done and the area to the left heel continued to close around the slightly purple tissue, due to poor circulation. The note specified " NP assessed " the resident to have [MEDICAL CONDITIONS]. The nursing note documented they were to elevate the resident ' s leg on a pillow, " continue treatment and monitor " . During the interview with CNA #3 (on [DATE] at 1:15PM) she stated that on [DATE], the resident ' s leg was purple from the mid calf down, and it remained purple with elevation. " I told the nurse it was purple, but from my knowledge, they were just elevating the leg. " The attending physician was interviewed via telephone (on [DATE] at 9:45 AM) regarding his awareness of the resident ' s left lower extremity. The physician was asked if the RN Manger informed him when they did rounds together at the facility on [DATE]. He replied that " the nurse manager did not tell me. " LPN #2 was interviewed (on [DATE] at 11:45 AM) and stated she " thought the nurse manager did rounds with the physician " on [DATE], but she was unsure what was discussed. On [DATE] at 10:00 AM, the RN Manager nursing note documented an area on the resident ' s left heel was " extremely purple; left heel wound starting to look worse due to poor circulation. " The note specified the resident ' s leg was elevated on the pillow; her foot was " purple and cool to touch. The NP to assess again. " At 10:15 AM on [DATE], and LPN #1 nursing note documented the dressing was changed to the resident ' s left heel, revealing a moderate amount of bloody drainage. The foot and heel were noted to be very purple and the wound looked " worse due to poor circulation. " The note documented the resident was " non compliant with keeping the left leg elevated on pillows. " The note documented the " nurse manager (was) aware " , and NP #1 was " to assess the resident in the morning. " During a telephone interview with the RN Manager (on [DATE]), the RN was asked why the attending physician was not notified of the status of the resident ' s left lower extremity. The RN Manager stated she did not call the physician " because the NP (NP #1) was following the resident, and knew " the resident ' s status. An LPN #1 nursing note at 1:30 PM on [DATE] documented the family visited the resident and " held the (resident ' s) left leg up continually for a half hour or so. " The note documented " color returned during that time to the left foot. " The resident was very upset and did " not want anyone to touch her left foot. " The surveyor interviewed NP #1 (on [DATE] at 12:30 PM) who stated she did not work on [DATE] and [DATE]. The NP stated she did not see the resident until [DATE]. The facility ' s other NP, (NP #2) was interviewed on [DATE] at 12:30 PM. She stated she worked on [DATE] and [DATE], but did not see the resident on those days. Review of the 24 hour report for [DATE] to [DATE], revealed no documentation entries that specified nursing communicated the status of the resident ' s left lower extremity to NP #1 or NP #2 during that time. The RN Manager provided the surveyor with her written statement (dated [DATE]) that specified on [DATE] the resident ' s whole foot was purple, cool to touch and was able to feel a faint pedal pulse. She documented she did not call the attending physician, because when the foot was elevated, it would return back to normal color and a pedal pulse was detected. The RN Manager, interviewed (on [DATE] at 11:00 AM), stated LPN #1 went to her on [DATE] and said the resident ' s foot " looked worse. " From the mid calf, down to the whole foot, was a darker purple, but a pulse was detected. The resident ' s foot was elevated and returned to normal color. The RN stated the resident ' s family came in and she told them the NP #1 was off and she would ask NP #1 for a consultation on [DATE]. On [DATE], the resident ' s comprehensive care plan (CCP) was updated and documented the resident ' s left heel had " decreased blood flow to wound area, dark purple/black; NP was to assess. " The CCP specified staff were to " keep left foot/leg elevated at all times on pillows. " On [DATE] at 12:40 PM, a nursing note documented NP #1 ordered arterial Doppler studies (circulation test) on both of the resident ' s legs, scheduled for [DATE]. When CNA #1 was interviewed (on [DATE] at 12:30 PM), he stated when he worked on [DATE], the resident ' s foot from the ankle down was severely blue, and it returned to normal color when it was elevated. The RN Manager was interviewed (on [DATE] at 11:00 AM) regarding the status of the resident ' s left leg on [DATE]. The RN Manager said NP #1 came in during that morning, and tried to get a Doppler study, " but there was no availability until [DATE]. " NP #1 ' s " acute note " , (dictated and typed on [DATE] regarding her [DATE] visit) documented " staff and the resident ' s family have noticed her left foot has become more discolored. " This NP note documented the resident " states her foot aches this morning " and would not be more specific. NP #1 noted the resident had dementia, [MEDICAL CONDITION], a history of long term ulcer on her left heel, and " chronic pain in her foot " The note documented staff " noticed particularly the sole of her foot to be more discolored, a darker purple in color. " NP #1 specified the resident ' s foot was " cool to touch " and she was " not able to palpate pedal pulses. " The NP documented she " did not observe the wound " and wrote the resident ' s " dressing was intact " , with no drainage on the dressing. NP #1 ' s note documented the resident ' s lower leg was " pale in color, slightly cool to touch " , and the resident ' s " knees (were) crossed " and she was " kicking her foot in the air. " NP #1 ' s note specified staff reported the resident ' s family " would like and evaluation done. " NP #1 wrote she contacted the outside radiology resting agency who would not be able to do the Doppler study until [DATE], due to the timing of their technician. " NP #1 documented she " would follow up when those results are available " , staff were to " continue to monitor it and call the on-call physician for any other changes. " NP #1 was interviewed (on [DATE] at 12:30 PM) regarding the status of the resident ' s leg and foot on [DATE]. The NP stated she did not get a pedal pulse on the left foot. The resident was lying with her foot in a reclining wheelchair with her legs elevated. The left leg was cool and pale with the sole of the foot a reddish purple color with no pulse. NP #1 stated she did not send the resident to the emergency room (ER) " because it was the sole of her foot and not the entire leg. " She stated there were no drastic changes in the resident at that time. She said she ordered the Doppler study that was scheduled for [DATE] and called the family who were " ok with that. " She said she did not inform the resident ' s attending physician, as she " was taking care of it. " June Review of physician orders [REDACTED]. " At 9:00 PM on [DATE], LPN #1 ' s nursing note documented the resident was only " out of bed for supper due to poor circulation in the left leg " , and was non-compliant with keeping it elevated when up in the wheelchair. The note specified the color to her left leg was " purple at times " , was " cool to touch " , and specified the resident cried out when touched. LPN #1 was interviewed (on [DATE] at 11:44 AM) who stated the resident ' s leg " was worsening " on [DATE] (Friday). She stated she had never seen the resident ' s leg " that purple before. " She said the resident ' s leg was cool and her left heel was purple. She said she brought the RN Manager in to check it. LPN #1 stated the RN told NP #1 saw it, said it was [MEDICAL CONDITION], and advised them to keep the resident ' s leg elevated. LPN #1 said the resident was in pain and it progressed until she was sent out. LPN #1 stated that you could tell the resident ' s circulation was decreasing by the changes to the area. When LPN #1 was re-interviewed (on [DATE] at 2 PM), she was asked if there was a reason she did not call the resident ' s attending physician when she noted the resident ' s left leg was " worsening " . LPN #1 responded that she " didn ' t remember. " On [DATE] at 6:00 AM, a nursing note documented the resident refused morning medications and was calling out again most of the shift. The note specified the resident " calls out when repositioned in bed " . At 1:00 PM, LPN #2 nursing note documented the resident was " kept in bed this shift to elevate the left leg was much as possible. " The note specified the resident ' s foot and heel were " bluish black " , and " now " the top of her foot and her toes were " swollen " . The resident was " crying out on and off all morning. " Review of the 24 hour report from [DATE] to [DATE], revealed no documented entries that specified nursing communicated the status of the resident ' s left lower extremity to NP #1 or NP #2 during that time. When NP #1 was interviewed (on [DATE] at 12:30 PM) regarding the status of the resident ' s left leg and foot, she stated she did not see the resident on [DATE] or [DATE]. At 6:30 AM on [DATE], RN 32 nursing note documented " advised of status of resident ' s foot and leg - left foot dark purple to black and extending up to (the) knee - purple and green in color, foul odor. " The note specified the resident ' s left heel had an " unstageable " wound. The note specified the resident ' s son was notified and aware of the changes. The nurse documented the physician was notified at 6:35 AM, and ordered the resident to be transported to the hospital emergency room (ER) for evaluation. At 7:07 AM, a nursing note documented an ambulance transported the resident to the hospital. When LPN #2 was interviewed (on [DATE] at 11:45 AM), she stated that on [DATE], the resident ' s toes and foot were darker. She said she " called the supervisor " and the resident was sent out to the hospital. The facility ' s patient transfer form, dated [DATE], documented the resident needed an " evaluation of the left leg " due to a " heel ulcer, poor circulation, (and) increased pain. The handwriting on this transfer form documented the resident ' s left leg was " progressively worsening since [DATE], increased pain. No circulation, and swollen/blue black. " The [DATE] physician ' s ER record, documented " per report form the nursing home " , the resident " started having some skin changes on [DATE], (2010) that subsequently progressed; " and was " subsequently found to have a cold, pulseless left lower extremity on [DATE]. " In the emergency room , the resident was described as being hypotensive (low blood pressure), [MEDICAL CONDITION] (rapid heart beat), and screaming in pain. The resident was noted to have a left lower extremity that " was obviously gangrenous, extending up into the calf. " There was an odor present, with notable darkened skin up to the mid calf. The patient had severe pain on any movement, with cold pulseless foot, and a distinct odor present. The note specified the resident cried out in agony, with any movement or palpation. Surgery was consulted and they recommended amputation above the knee. The family decided to allow the patient comfort and dignity in the final days of her life, without surgery. The patient was admitted to Comfort Care service. The hospital discharge summary, dated [DATE] documented resident expired at 11:40 AM on [DATE]. The resident ' s attending physician returned a call from the surveyor (on [DATE]) and left a message that he did not see the resident from [DATE] through [DATE], according to the facility ' s records. He stated he saw the resident prior to that time. When the resident ' s attending physician was interviewed via telephone (on [DATE] at 11:00 AM), he stated he reviewed the resident ' s medical record and it was " concerning " that there was no (pedal) pulse. He said he would have had the Doppler performed immediately. He stated that on [DATE] at 9:00 PM, nursing notes documented the resident ' s leg was cool to touch and there was no pulse. He stated that information revealed " things were changing " and that a " stat " (immediate) Doppler and trip to the emergency room were indicated. The physician stated that on [DATE] at 1:00 PM, there was a critical change, based on nursing notes, when the resident ' s foot was a purplish color and distending. In summary, the resident experienced harm, as the facility: -did not monitor the status of the residents left lower extremity when significant changes occurred; -did not notify the resident ' s physician when her left leg and foot became purple in color, and cool to the touch (from [DATE] until [DATE]); -did not ensure the resident received prompt medical evaluation when her foot was identified to have no pulse on [DATE] and an outpatient Doppler was not available for three days; -did not ensure the resident was evaluated by a medical provider on [DATE], when resident ' s foot and heel were " bluish black " , and to top of her foot and her toes were noted to be " swollen " . 10 NYCRR 415.12