Every finding on record at Carthage Center for Rehabilitation and Nursing

Based on observations, record review, and interviews (QIES Intake 3038191), the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two of two meals (lunch meal on 07/21/2026 and breakfast meal on 07/23/2026) and for three of nine anonymous residents present at the resident group meeting. Specifically, the 07/21/2026 and 07/23/2026 meal trays included hot foods served below 130 degrees Fahrenheit, cold foods served above 49 degrees Fahrenheit, and some foods were not palatable; and three anonymous residents at the resident group meeting stated the hot food was served cold and meals were not appetizing. Findings include: The facility policy Food Temperatures Policy, effective 05/28/2025, documented food temperatures must be recorded on hot and cold foods prior to service using the food temperature log to maintain a high level of quality assurance, to monitor potentially hazardous food temperatures, and to ensure foods were provided in a safe, palatable manner. The April 2026, June 2026, and July 2026 Food Service Committee Meeting notes documented the residents felt the vegetables served were soggy. During an interview on 07/21/2026 at 10:42 AM, Resident #34 stated the food was cold and did not taste good. During an anonymous resident group meeting on 07/21/2026 at 11:03 AM, three residents stated the hot food was served cold and was not always appetizing. During an observation on 07/21/2026 at 12:22 PM, Resident #81's lunch tray was tested, and a replacement was ordered. Unit Helper #34 was present and verified food temperatures as follows: the meatloaf was 129 degrees Fahrenheit, the gravy was 118 degrees Fahrenheit, the squash was 114.3 degrees Fahrenheit, the water was 58.3 degrees Fahrenheit, and the applesauce was 50.4 degrees Fahrenheit. The meatloaf was pink and appeared undercooked, the gravy was congealed, and the squash had a mushy texture. During an observation on 07/23/2026 at 7:52 AM, Resident #34's breakfast was tested, and a replacement was ordered. Licensed Practical Nurse #23 was present and verified food temperatures as follows: the cranberry juice was 53.4 degrees Fahrenheit, and the cream of wheat was bland and pasty. During an interview on 07/23/2026 at 10:58 AM, Certified Nurse Aide #7 stated residents said the food was not warm enough and did not taste good but improved in the last couple months. If a resident did not like the food, they offered to warm it up or offered a substitution. During an interview on 07/23/2026 at 11:10 AM, Licensed Practical Nurse #12 stated residents complained about the food being too cold, not being cooked enough, and not looking appetizing. When they got complaints during meals, they offered to heat the food or offered an alternative. During an interview on 07/24/2026 at 9:19 AM, [NAME] #31 stated the food temperatures were tested prior to serving. Food should look appealing as people eat with their eyes first. The meatloaf looked pink when it was cooked but 129 degrees Fahrenheit was too cold. All hot food except fish should be above 135 degrees Fahrenheit when served. The gravy should be served at a higher temperature. The squash came frozen, but they did their best to cook it well. The cold food should not be above 40 degrees Fahrenheit. During an interview on 07/24/2026 at 9:35 AM, the Food Services Director stated food temperatures were checked twice before being sent to the residents. The hot food should not drop below 140 degrees Fahrenheit, and the cold food should be below 40 degrees Fahrenheit. The meatloaf should not look pink or undercooked. The squash came sliced and frozen and they tried different ways to cook it but once it went into the pan, it broke down. Food was eaten with eyes first and residents deserved to have their food served warm. 10 New York Codes, Rules and Regulations 415.14(d)(2)

Based on observations, record review, and interviews (iQIES Intake 2601518), the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of pressure ulcers for one of six residents (Resident #3) reviewed. Specifically, Resident #3's pressure ulcer treatment was not administered by Licensed Practical Nurse #23 as ordered, their pressure relieving boots were not implemented as planned, and their pressure reducing air mattress was not set at the appropriate weight. Findings include:The facility policy Skin and Pressure Injury Prevention, revised 06/27/2024, documented prevention measures for a person in bed included frequent position changes, pressure relieving device on the bed, and when in bed every attempt was made to offload pressure to the heels (keep the heels off the bed). Interventions included, but were not limited to, heel boots and pillow placement from knee to ankle. Resident #3 had diagnoses including right sided stroke, generalized muscle weakness, and difficulty walking. The 06/15/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had moderate cognitive impairment; was dependent for lower body dressing, putting on/ taking off footwear, and bed mobility; had unhealed pressure ulcers; a pressure reducing device for bed; received applications of ointments/ medications other than to feet; and did not reject care. The Comprehensive Care Plan documented:-On 04/26/2024 and revised 03/18/2026, the resident was at risk for pressure injury development related to chronic disease process/ multiple co-morbidities and impaired mobility. Interventions included low air-loss mattress for the bed and offloading heel boots bilaterally.-On 03/12/2026 the resident had an alteration in skin integrity and had actual pressure injuries of a Stage 4 (full thickness tissue loss with exposed bone, muscle or tendon) on the right heel and an unstageable (full thickness tissue loss in which the base of the ulcer is covered with dead tissue) on the left heel. Interventions included treatments were applied per order. Physician orders documented:-On 03/18/2026 the low air loss mattress setting was to be checked closest to the resident's current weight and mattress functionality every shift for monitoring.-On 07/08/2026 cleanse left heel with Dakin's solution (wound wash), pat dry, apply Hydrofera Blue (antibacterial wound treatment), skin prep (film to protect the skin) to surrounding skin, cover with abdominal pad (thick absorbent pad) and wrap with Kerlix (gauze roll) every Tuesday, Thursday, Saturday, and as needed.-On 07/15/2026 cleanse right heel with Dakin's solution, pat dry, apply Hydrofera Blue, skin prep to surrounding skin, cover with abdominal pad and wrap with Kerlix, every Tuesday, Thursday, Saturday, and as needed. Resident #3 was observed lying in bed on their back with their heels directly resting on the mattress with their bilateral heel boots in the chair next to the television at the following times:-On 07/21/2026 at 10:52 AM-On 07/22/2026 at 9:25 AM and 11:03 AM-On 07/23/2026 at 8:54 AM. On 07/01/2026 the resident's weight was documented as 190.2 pounds. The following observations of Resident #3's mattress settings were made on: -07/21/2026 at 10:52 AM at 250 pounds. -07/22/2026 at 9:25 AM and 11:03 AM at 250 pounds.-07/23/2026 at 8:54 AM at 550 pounds.-07/23/2026 at 1:31 PM at 550 pounds. The July 2026 Treatment Administration record documented the air mattress was checked for weight setting and function every shift. The July 2026 Certified Nurse Aide Tasks documented the bilateral heel boots were in place every shift except for no documentation on the night shift on 07/11/2026 and 07/12/2026. During a wound care observation and interview on 07/23/2026 at 11:14 AM, Resident #3 was lying in bed on their back with their heels resting directly on the mattress, the bilateral heel booties were in the chair next to the television, and the air mattress was set to 550 pounds. Licensed Practical Nurse #23 changed the resident's wound treatments with the assistance of Registered Nurse #24. Licensed Practical Nurse #23 applied Silvasorb (antimicrobial containing silver) gel and collagen powder (absorbs extra fluid and provides structure for new tissue growth) to the Hydrofera Blue dressing for both the left and right heels. After the dressings were changed, Licensed Practical Nurse #23 placed the bilateral heel boots on the resident and stated they protected the resident's heels. They put them on after they did the wound treatments and did not think the resident wore them at night. They were not sure if the certified nurse aides ever put the heel boots on. The resident did not wear them every day but thought they wore them yesterday. They stated the resident also had an air mattress for pressure reduction. At 11:46 AM, they exited the room and did not check the setting of the air mattress which was set at 550 pounds. At 12:42 PM, the air mattress was still set at 550 pounds. During an interview on 07/23/2026 at 1:24 PM, Licensed Practical Nurse #23 looked up the treatment orders for Resident #3's bilateral heels. They stated they did not see Silvasorb gel or collagen powder in the treatment order, they did not follow the order and should not have applied those items. They completed the dressing change that way because that was the way they recalled doing it with the wound doctor last week. They stated they were supposed to follow physician orders. Licensed Practical Nurse #23 was observed actively signing off the air mattress was checked on the Treatment Administration Record during the interview. They stated they thought it was charted somewhere that the air mattress was checked but they were not sure and thought it might be documented weekly. The air mattress needed to be checked to ensure the weight setting was consistent with the resident's weight. During an interview on 07/23/2026 at 4:41 PM, Certified Nurse Aide #25 stated if a resident needed heel boots it was in the care plan and Kardex (care instructions). It was part of their charting to sign off if the boots were in place and if a resident refused it was charted as a refusal, and they notified the nurse. Resident #3 had dying skin on their feet and the nurses changed their dressings. They stated they gave the resident a break from the heel boots during the day and made sure to put them on before their shift was over so the resident could wear them at night. During an interview on 07/24/2026 at 11:58 AM, Licensed Practical Nurse Unit Manager #17 stated Resident #3 had bilateral heel sores, and their heel boots should be implemented. The resident could not remove their own boots, and they were unaware of the resident ever refusing to wear them. If the certified nurse aides signed off the heel boots were on, they should be on. If their air mattress was signed off as checked, it meant the nurse went into the room, felt the mattress was inflated and checked to ensure the controller was set to the resident's most current weight. The resident's air mattress setting at 550 pounds was not appropriate for their weight and if the nurse checked it as ordered, they should have adjusted the dial to the correct weight setting. Licensed Practical Nurse #23 should have opened the actual chart and read the wound treatment order prior to completing the treatment. The nurses should follow the order because that was what the provider wanted. 10 New York Codes, Rules, and Regulations 415.12(c)(1)

Based on observations, record review, and interviews (iQIES Intake 2808135), the facility failed to ensure the resident environment remained free of accident hazards for one of four residents (Resident #63) reviewed. Specifically, Resident #63 had a history of a fall from bed resulting in a lumbar spine fracture and their bed was observed not in the lowest position as planned. Findings include:The facility policy Falls Prevention and Management, revised 04/29/2026, documented the interdisciplinary team completed a post-fall analysis, revised the care plan as indicated, and provided education to the resident and staff regarding the care plan revisions. Interventions included, but were not limited to, proper bed height and position. Resident #63 had diagnoses including dementia, muscle weakness, and restlessness with agitation. The 04/18/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident had severe cognitive impairment, required supervision with transfers and bed mobility, and had one fall with major injury. The 03/08/2026 at 11:07 PM Licensed Practical Nurse #37 progress note documented the resident was heard calling for help and was found sitting on the floor by their bed. Due to pelvic pain the resident was transferred to the hospital. Fall prevention interventions were reviewed and implementation was verified. The 03/08/2026 Hospital Discharge Summary documented the resident needed fall prevention measures instituted after a fall from the bed resulting in a subacute compression fracture of the fourth lumbar vertebrae (lower spine fracture). The Comprehensive Care Plan initiated 05/17/2022 documented the resident was at risk for falls and had an actual fall related to confusion and psychoactive drug use (date of fall not documented). Interventions initiated on 03/08/2026 included low bed and bed in lowest position. The undated care instructions (Kardex) documented low bed and bed in lowest position for safety. Resident #63 was observed lying in bed with the bed approximately 24 inches off the ground (not lowest position) at the following times:-On 07/21/2026 at 9:16 AM.-On 07/22/2026 at 12:18 PM and 2:24 PM.-On 07/23/2026 at 8:59 AM.-On 07/24/2026 at 9:29 AM. During an observation and interview on 07/24/2026 at 9:54 AM, Resident #63 was lying in their bed, the bed remote was hanging from the bed frame at the head of the bed, and their bed was approximately 24 inches above the ground. Certified Nurse Aide #15 stated the bed was not in the lowest position. They used the bed remote and lowered the bed to approximately 12 inches off the ground to the lowest setting. They stated they never saw the resident utilize the bed remote to move their own bed. All residents' beds should be in a low position for fall risk safety. During an interview on 07/24/2026 at 9:59 AM, Licensed Practical Nurse #14 stated residents were at risk for injury if their bed was not in the lowest position. Resident #63 had not had a fall in a long time and mostly just stayed in bed. They did not notice the resident's bed was not in the lowest position. During an interview on 07/24/2026 at 10:05 AM, Licensed Practical Nurse Unit Manager #6 stated Resident #63 had a back fracture in March 2026 after rolling out of bed. At that time, they added a low bed intervention to the resident's care plan. The information from the care plan carried over to the Kardex (care instructions) and staff were expected to reference the information daily and follow it. Anytime the resident was in bed, their bed should be in the lowest position to minimize injury if they did fall. 10 New York Codes, Rules, and Regulations 415.12(h)(1)(2)

Based on record review, observation, and interviews during the recertification and abbreviated (NY00348460) surveys conducted 9/23/2024-9/26/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 resident units (North and South units) reviewed. Specifically, the South unit common area had a stained carpet, four burned out lights, a broken light fixture, the unit shower was missing floor and wall tiles, and the dining room countertop was damaged; the North unit resident room [ROOM NUMBER] had a dirty floor mat that smelled of mildew and cobwebs on the wall. Findings include: The facility policy, Cleaning/Disinfecting Resident Care Items and Equipment, revised 3/13/2024, documented reusable resident care items and equipment would be cleaned and disinfected according to the current Center for Disease Control and Prevention recommendations for disinfection of healthcare facilities. The facility policy, Environmental Services: Vacuuming Carpets, revised May 2018, documented if there was a stain on a carpet it was cleaned according to the carpet cleaning procedure in order to maintain a safe and sanitary environment. The following observations were made on the North unit: - on 9/23/2024 at 11:03 AM, resident room [ROOM NUMBER]'s floor mat was dirty with dried debris and crumbs. When the mat was lifted there was a smell of mildew. There was a cobweb on the wall in the corner of the room. - on 9/24/24 at 8:31 AM, resident room [ROOM NUMBER]'s floor mat had dried debris. When the mat was lifted it smelled of mildew and the floor tiles were stained. There were cobwebs in the upper and lower corner of the wall above the mat. The following observations were made on the South unit: - on 9/24/2024 at 9:56 AM, the dining room countertop was damaged/chipped and the drawers under the countertop were loose and not aligned. - on 9/24/2024 at 10:08 AM, the unit shower room had multiple missing floor and wall tiles. - on 9/24/2024 at 10:26 AM, the unit hall bathroom had a broken wall tile at the bottom of the door. - on 9/24/2024 at 10:42 AM, the unit common area had several large, stained areas in the carpet, four burned out lights, and a broken light fixture. During an interview on 9/24/2024 at 01:31 PM, Housekeeper #5 stated resident rooms should be mopped daily but they could not always be done because of short staffing. They stated floor mats were cleaned every day. If a resident was not in their room the mat was wiped down, set upright to dry, and the floor was mopped. If the resident was in their room the mat was wiped down but left in place. They stated it was important to clean the rooms and floor mats to prevent the spread of infection. During an interview on 9/25/2024 at 1:00 PM Licensed Practical Nurse #6 stated floor mats were ordered from maintenance and cleaned daily by housekeeping. If there was a small spill nursing staff should clean it, however if the floor mat required additional cleaning it was sent for a power washing. During an interview on 9/26/2024 at 10:38 AM Housekeeper #8 stated the day room rug was very stained and had not been shampooed in over one year because the porter was responsible for shampooing the rug and that position had been vacant for approximately one year. They stated the rooms had not been painted in nearly nine years. They stated the rooms and common areas were not homelike. During an interview on 9/26/2024 at 12:55 PM Maintenance Director #7 stated they were aware of the lights being out in the South unit common area. They were not aware of the other environmental concerns as there were no work orders for the shower tiles or countertops. They stated it was important to keep the environment homelike for the safety of both residents and staff. 10 NYCRR 415.29(j)(1)

48675 Based on observation and interviews during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 3 of 3 meals (the 9/24/2024 lunch meal, the 9/25/2024 special Fall festival meal, and the 9/25/2024 lunch meal) reviewed; for 7 of 7 anonymous residents present at the Resident Council meeting; and for 2 additional residents interviewed (Residents #178 and #180). Specifically, the 9/24/2024 and 9/25/2024 lunch meals were not flavorful; the 9/25/2024 Fall festival meal was not served at palatable and appetizing temperatures; 7 of 7 anonymous residents at the Resident Council meeting stated the food was often not appetizing and served cold; and 2 residents (Resident #178 and #180) stated the food was not flavorful and was served cold. Findings include: The facility policy, Rapid Cooling of Food, revised 1/2023, documented temperature control for food safety would be maintained at a temperature greater than 135 degrees Fahrenheit or cooled to a temperature of 40 degrees Fahrenheit. During an interview on 9/23/2024 at 11:25 AM, Resident #178 stated the food was bland, did not taste good, and was served cold. During an interview on 9/23/2024 at 11:42 AM, Resident #180 stated the food had an unpleasant taste and texture and was usually served cold. During a resident group interview on 9/23/2024 at 1:32 PM, 7 anonymous residents stated the food did not taste good and was not served hot. During an interview on 9/24/2024 at 9:40 AM, Certified Nurse Aide #30 stated residents complained the food did not taste good and was not served hot. During a lunch meal observation in the main dining room on 9/24/2024 at 12:04 PM, a lunch meal tray was tested . The beef stroganoff was measured at 135 degrees Fahrenheit, and the beef tasted bland and was difficult to chew due to a rubbery texture. During a Fall festival lunch meal observation in the main dining room on 9/25/2024 at 12:08 PM, a lunch meal was tested . The corn dog was measured at 100 degrees Fahrenheit, the sweet potato fries were measured at 99 degrees Fahrenheit, and the corn on the cob was bland, chewy, and mushy. During a lunch meal observation on 9/25/2024 at 12:32 PM, Resident #72's meal tray was tested , and a replacement tray was ordered. The barbeque chicken was bland, and the barbeque sauce tasted like plain ketchup. The corn on the cob was bland, chewy, and mushy. During an interview on 9/26/2024 at 9:27 AM, Activities Aide #42 stated there was miscommunication during the Fall festival meal regarding who was supposed to take the temperatures of the food that was being served. The activities department obtained the food from the kitchen, and they served it to the residents. They stated they should have taken the temperature of the food that was being served even though they used a portable stove to keep the food hot. During an interview on 9/26/2024 at 9:46 AM, the Food Service Director stated the activities and dietary department cooked the food for the Fall festival. The cook should have taken temperatures of the food but there was miscommunication between the departments, they were short staffed, and the cook was doing other jobs and not just cooking. They were unsure when the last test tray was done. The registered dietitian used to do test trays, but they were working remotely so the test trays were not being done regularly. They stated they planned to start doing them again. They usually tasted the food while it was being cooked. The cooks had recipes to follow and were not able to add salt, but used spices like garlic and pepper, and they would add salt and pepper on resident trays if they were allowed to have it. The corn dogs and sweet potato fries were not hot enough and should have been served at a minimum of 140 degrees Fahrenheit and the food served to the residents should always be palatable. During an interview on 9/26/2024 at 10:13 AM, the Director of Activities stated the food for the Fall festival was reheated using a portable stove after it was cooked. The cook took the food temperatures when it came out of the oven and told them the temperatures were okay. They were unsure what temperature the food should have been kept at and normally the kitchen staff would have helped, but they were short staffed. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 main kitchen. Specifically, in the main kitchen food was not maintained at proper temperatures, there was outdated food, and the dishwasher was not in proper working order. Findings include: The facility policy, Cleaning Standards, revised 1/2023, documented high standards of cleanliness and sanitation would be defined and maintained. Cleaning was defined as the use of water, chemicals, and elbow grease to remove all food and debris from equipment and work services. Sanitizing was the use of chemicals or temperature to kill microorganisms remaining on surfaces after they have been cleaned. The facility policy, Food Storage, revised 5/10/2024 documented sufficient food storage facilities were provided to keep foods safe, wholesome, and appetizing. Food would be stored in an area that was clean, dry, and free from contaminants. Food would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. The facility policy, Rapid Cooling of Food, revised 1/2023 documented time/temperature for food safety would be maintained at temperatures >135 or cooled to temperatures 40 degrees or below. Time/temperature control for food safety including meats, eggs, poultry, seafood, cut melon, milk, yogurt, and cottage cheese pose a risk for growth of harmful pathogens when kept in temperature danger zones for greater than 4 hours. The procedure documented the following: - do not cover until cooled - measure temperature of product at final temperature then record; record time reached to 135 degrees. After 60 minutes record temperature. At the second hour product should have been at or below 70 degrees, if not obtained, product must be discarded. Record time, temperature and initial for each hour up to the 6th hour or until the product reached 40 degrees or below. Scrambled Eggs: During an observation on 9/24/2024 at 11:42 AM scrambled eggs in a closed one-gallon plastic container were in the reach in cooler and were labeled with the date of 9/24. The eggs were measured at 94 degrees Fahrenheit. During an interview on 9/24/2024 at 12:10 PM, [NAME] #44 stated the cooked scrambled eggs were put into the reach in cooler right after breakfast which was between 8:30 AM and 9:00 AM. The stated they did not check the temperature of the eggs or monitor them after they were put into the cooler. The leftovers were usually used for the pureed option on the next day's meal service. Meat could be left out after it was cooked to cool down slowly for about 2 hours, but they did not remember the cooling requirements after that. They did not document the cooling process and they were not aware the eggs needed to be cooled properly. During an observation and interview on 9/24/2024 at 12:16 PM, the scrambled eggs were measured by the surveyor and [NAME] #44 at 87 degrees Fahrenheit. [NAME] #44 stated the scrambled eggs were not cooled properly and they would voluntarily discard the eggs. During an interview at 9/24/2024 at 12:26 PM, Food Service Director stated cooling was done by cutting in half large roasts or icing it down to get to a temperature or below 41 degrees Fahrenheit. They stated the cooling time was completed within four hours; however, they were not sure. They stated the scrambled eggs that were measured over 90 degrees Fahrenheit and were in the cooler for over three hours, did not meet the cooling requirements, and should have been discarded. Improper cooling/cold holding turkey salad: During an observation and interview on 9/24/2024 at 11:46 AM, there was a large bowl of turkey salad located in the walk-in cooler covered with multiple layers of plastic wrap which measured at 49.6 degrees Fahrenheit. The Food Service Director stated it was made by [NAME] #44. During an interview on 9/24/2024 at 12:04 PM, [NAME] #44 stated they made the turkey salad approximately 30 minutes ago. They ground the turkey in a food processor, added mayonnaise from the walk-in cooler, mixed it together in a bowl, covered it with plastic wrap, and returned it to the walk-in cooler. They stated it should be cooled to the proper temperature, and the proper temperature was the walk-in cooler temperature, but they were not sure what that numerical temperature was. They stated they took and documented food temperatures during and after cooking, but they did not document or measure a temperature of the turkey salad. When food needed to be cooled down quickly, they used an ice bath, however, they were not sure the time limit required to properly cool food. During an observation and interview on 9/24/2024 at 12:22 PM, the temperature of the turkey salad was remeasured with [NAME] #44 and measured at 49.5 degrees Fahrenheit. [NAME] #44 stated the turkey salad was not cooling properly. The product was uncovered and moved to the walk-in freezer to rapidly cool the product for today's dinner meal. During an interview and observation at 9/24/2024 at 12:26 PM, the Food Service Director stated the turkey salad was not cooled properly because it did not change temperatures after being in the cooler for nearly one hour. During an observation on 9/24/2024 at 1:33 PM, the temperature of the turkey salad was measured with [NAME] #44 at 40 degrees Fahrenheit. Corporate Registered Dietitian #45 was showing [NAME] #44 how to complete a cooling log sheet. Outdated food in the kitchen: During an observation on 9/24/2024 at 11:42 AM, a closed one-gallon plastic container located in the reach in cooler located opposite the walk-in cooler contained cooked rice that was labeled with the date 9/20/2024. During an interview on 9/24/2024 at 12:18 PM, [NAME] #44 stated the leftover rice had been in there for more than three days and should have been discarded. During an interview at 9/24/2024 at 12:26 PM, the Food Service Director stated leftovers were discarded after three days and the rice should have been discarded. They stated they were responsible for checking the coolers along with the cooks, and this process was not documented. Unclean and uncleanable surfaces/ steam table in disrepair/ dishwasher out of service: During an observation and interview on 9/23/2024 at 10:34 AM the main kitchen steam table had no lights to signify that it was functioning, and the front service rail bars of the steam table were taped in the corners (not smooth and easily cleanable). The front of the oven doors had dried debris on them, the handles on the sink were dripping, the basement dry food storage area had a box with folded boxes in an area near the entry door, and there was an unsanded and unpainted dry wall patch on the left wall near the hallway entrance approximately 1-foot by 1-foot. The Food Service Director stated they recently discussed concerns about the steam table to maintenance and Administration about it needing to be fixed or replaced. During an interview on 9/25/2024 at 3:22 PM the Administrator stated they were aware the dishwasher was broken, and disposable plates and utensils were used during that time. They called 3 different contractors, and one was able to get the parts needed to repair it. Additionally, the steam table lights not working were not a major concern if staff was taking temperatures of food prior to, during, and after meal services. The surgical and duct tape and zip ties holding together the tray line bars were not cleanable surfaces and would be corrected soon. During an interview on 9/26/2024 at 10:09 AM the Director of Food Services #33 stated when the dishwashing system was not functioning properly, they notified maintenance and the Administrator. 10NYCRR 415.14(h) 43754

Based on record review and interview during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #72) reviewed. Specifically, Resident #72 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required. Findings include: The facility policy, Notice- Advances Beneficiary Notice, dated 7/2019 documented the Advance Beneficiary Notice of Non-coverage was to be issued by the facility where Medicare payment was expected to be denied. The notice must be provided within enough time to provide the beneficiary enough time to make an informed decision on whether or not to continue to receive services and accept potential financial liability not covered by Medicare. The notice must give a brief explanation why the beneficiary's needs did not meet Medicare coverage guidelines. The Center for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055, expiration date 1/31/26, documented a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (form 10055) must be issued by providers to beneficiaries in situations where Medicare payment was expected to be denied. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice prior to services ending. Resident #72 had diagnoses including muscle weakness, anxiety, and traumatic brain injury. The 9/17/2024 Minimum Data Set assessment documented it was a Skilled Nursing Facility PPS (Prospective Payment System) Part A Discharge (end of stay) assessment with a start date of 7/1/2024 and an end date of 9/17/2024. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055 letter documented Resident #72's effective end date of services was 9/17/2024. Business Office Manager #16's handwritten note documented the form was mailed to the resident's representative as the resident was unable to sign for themselves (no date documented when the form was mailed). The letter was not dated. The United States Postal Service Certified Mail Receipt addressed to the resident's representative did not document a date the letter was mailed by the facility. During an interview on 9/25/2024 at 4:21 PM, Business Office Manager #16 stated they sent the beneficiary letters as soon as the insurance company or therapy notified them of a pending cut from therapy. They should have put a date on the letter and certified mail forms when it was sent by the facility. There was no tracking mechanism by the facility. The resident remained in the facility and the facility charges were back dated and covered by Medicaid. The manager stated they should have documented when the letter was sent as it was to be sent at least 2 days prior to termination of services. During a telephone interview on 9/25/2024 at 4:30 PM, Resident #72's representative stated they received the beneficiary letter on 9/23/2024 from the post office and signed that the letter was received. The representative stated they would have appealed the non-coverage if they were aware earlier. They made numerous attempts to contact the facility regarding the reason for the discontinuation of services, and the facility had not called them back or given them an explanation as to why the resident was cut from therapy. 10 NYCRR 483.10 (g) (18)

Based on observation, record review, and interview during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure the discharge needs of each resident were identified and resulted in the development of a discharge plan for 1 of 1 resident (Resident #54) reviewed. Specifically, Resident #54 expressed the intention to be discharged to an assisted living facility and was not assisted with discharge planning or updated on the status of their discharge plan. Findings include: The facility policy, Discharge-Planning, revised 12/2019, documented the discharge planning process ensured residents had a discharge plan of continuing care that met their post-discharge needs and a goal of a safe and successful transition to the community, a lower level of care, or alternate healthcare facility. The Social Worker was responsible for the duties of Discharge Coordinator. The Discharge Coordinator developed a discharge plan that began on admission for each resident, initiated all necessary referral for post discharge care and needs, and documented the steps taken for discharge planning in the resident's medical record. Resident #54 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (lung disease), respiratory failure, and dependence on supplemental oxygen. The 7/8/2024 Minimum Data Set assessment documented the resident was cognitively intact, had no behavioral symptoms, required supervision or set-up assistance with most activities of daily living, was independent with transfers and ambulation, and active discharge planning was not occurring. The comprehensive care plan initiated 7/28/2024 documented the resident's placement was long-term care and the resident did not wish to be asked about returning to the community on all assessments. Interventions included participation in social/ recreational activities to promote well-being and support and encouragement were provided. The 4/26/2024 Physical Therapist #12 discharge progress note documented the resident had reached their goals upon discharge. The discharge recommendations were assistance with instrumental activities of daily living (preparing meals, managing medications, cleaning, getting around with transportation and managing money). The 4/26/2024 Occupational Therapist #13 discharge progress note documented the resident had reached maximum potential with skilled services and made consistent progress with skilled interventions. The 6/4/2024 Director of Social Work Social Services Assessment documented the resident was responsible for themself, and their goal was to be discharged to another facility/ institution. The resident was readmitted to the facility, and they were to remain long-term care and work on their well-being. There was no documented evidence the Director of Social Work discussed discharge goals and the need for long-term placement with the resident. The resident's Notice of Medicare Non-Coverage documented Medicare covered Skilled Nursing Facility Services would end on 6/20/2024. The resident signed the notice on 6/18/2024. The 8/5/2024 Psychiatric Mental Health Nurse Practitioner #10 progress note documented the resident reported they were waiting for assisted living placement. The 8/6/2024 Physician #9 progress note documented the resident was at their treatment and care plan goals and was to be discharged to assisted living if possible. The 8/24/2024 Psychiatric Mental Health Nurse Practitioner #10 progress note documented the resident reported that they continued to wait for assisted living placement. There was no documented evidence the possibility of discharge to an assisted living facility was discussed with the resident or if referrals were made. During an interview on 9/23/2024 at 10:08 AM, the resident stated they were trying to find somewhere else to live. During an interview on 9/25/2024 at 8:58 AM, the resident stated they went out with family yesterday. They went shopping, out to eat, and got a new cellular phone. Their social worker was supposed to be helping them get to an assisted living facility for the past 4-6 months. They asked their social worker every day, and their social worker told them they had not heard anything. When they talked to their social worker a couple of days ago, the social worker said they were going to call some facilities. They did not know if they had made any calls yet or to what facilities. They wanted to move closer to where they lived prior to coming to the facility. During an interview on 9/25/2024 at 12:59 PM, Certified Nurse Aide #15 stated the Director of Social Work was responsible for and assisted residents with discharge planning. Resident #54 did not need any assistance from the certified nurse aides. The resident bathed, brushed their teeth, washed their face, and dressed themselves independently. They thought the resident could probably live in an assisted living facility. During an interview on 9/25/2024 at 1:29 PM, Licensed Practical Nurse #14 stated the resident was independent with activities of daily living. It was important the resident went to a lower level of care to facilitate independence and it would be beneficial for mood and lifestyle. The resident spent their days either in their room or the dining room and if they were at an assisted living facility, they could go for a walk or do many different things. The Director of Social Work was responsible for assisting residents with discharges. During an interview on 9/25/2024 at 1:54 PM, the Director of Social Work stated the discharge process started on their first visit within 3 days of admission. They were the only social worker for the facility. Prior to discharge the resident had to be cleared by the physician, medical staff, and therapy. If a resident was appropriate to be discharged to assisted living, they sent out referral packets via facsimile. They then waited for call backs and followed up periodically if they had not heard anything back. When Resident #54 was discharged from therapy, discharge to assisted living was discussed. The resident wanted to go somewhere close to where they lived before, but they were not familiar with the facilities in that area. They stated the resident would do great in an assisted living setting. For the past 2 weeks the resident came to their office every morning and asked about moving to an assisted living facility and they told the resident they had not forgotten about them and that the process took time. It was important that progress of the process was communicated with the resident. They could not remember how long it was since the resident first approached them about moving to an assisted living facility but at that time there were long wait lists. They had not yet sent out any referral packets for Resident #54. The resident's family came to them today and asked about a transfer to another facility as well. 10NYCRR 415.11(d)(3)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00348460 and NY00345485) surveys conducted 9/23/2024-9/26/2024, the facility did not ensure 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 2 of 7 residents (Resident #15 and #43) reviewed. Specifically, Resident #43 was not assisted with removing unwanted facial hair, and Resident #15 had unkept hair and unclean and untrimmed fingernails. Findings include: The facility policy, Activities of Daily Living Care and Support, revised 3/13/2024, documented activities of daily living care and support would be provided for residents who were unable to carry out activities of daily living independently, in accordance with the resident's assessed needs, personal preferences, and individualized plan of care, that included but was not limited to supervision and assistance with: hygiene, mobility, elimination, dining, and communication. Nail care would be provided as needed for residents and facial hair would be groomed as per residents' preference and/or assessed needs. 1) Resident #43 had diagnoses including cerebral palsy (disorder that affects movement, muscle tone, and posture), muscle weakness, and repeated falls. The 7/8/2024 Minimum Data Set assessment documented the resident was cognitively intact, was dependent with toileting hygiene, shower/bathing, and lower body dressing, required setup or clean-up assistance with eating and oral hygiene, and did not refuse care. The comprehensive care plan initiated 6/14/2024 documented the resident required assistance with self-care and mobility related to impaired balance and limited mobility. Interventions included partial assistance with personal hygiene and substantial assistance with showering/bathing. The 9/2024 certified nurse aide care record documented the resident received personal care during the day and evening shift on 9/23/2024-9/25/2024. Resident #43 was observed at the following times: - on 9/23/2024 at 12:10 PM, in their room seated in their wheelchair. They had thick brown hair covering their upper lip and long gray/white hair under their chin. The resident stated they did not want facial hair. - on 9/24/2024 at 9:10 AM, in their room seated in their wheelchair. They had thick brown hair covering their upper lip and long gray/white hair covering their chin. - on 9/25/2024 at 9:38 AM, in their room seated in their wheelchair. They had thick brown hair covering their upper lip and long gray/white hair covering their chin. The resident stated they hoped staff had time to shave them because they did not want facial hair when they attended the Fall Festival activity. During an interview on 9/25/2024 at 1:10 PM, Certified Nurse Aide #34 stated they looked at the resident's care instructions to know how to properly care for each resident. Personal hygiene consisted of cleaning the resident head to toe, nail care, oral care, and shaving. They stated after they completed all personal hygiene, they documented the care was completed. If a resident refused, they would document the refusal and notify the nurse so they could reapproach the resident. They were familiar with Resident #43, they did not refuse care, and they assisted with their care that day. The stated they shaved the resident because they had a lot of facial hair, and they thought another certified nurse aide should have done it earlier that week when they were not working. It was important for the certified nurse aides to offer shaving whenever facial hair was present to maintain resident dignity. During an interview on 9/25/2024 at 3:42 PM, Licensed Practical Nurse #14 stated staff looked at a resident's care plan or care instructions to tell them how to properly care for the resident. Personal hygiene was completed each shift and consisted of washing a resident's face and body, nail care, hair care, shaving, and oral care. If a resident refused care, the certified nurse aides would notify the nurse so they could reapproach the resident. They had not been notified of any refusals by Resident #43. They stated it was important for the certified nurse aides to shave Resident #43 for their self-image and to maintain their dignity. During an interview on 9/26/2024 at 9:26 AM, Certified Nurse Aide #36 stated residents received showers twice a week and they would shave resident's when they were in the shower. They gave Resident #43 a shower on 9/23/2024 and they could not recall if they shaved the resident, but they normally would during a shower. Resident #43 never refused care but if they had, they would have notified the nurse. They stated it was important to shave Resident #43 whenever they had facial hair to maintain their dignity. During an interview on 9/26/2024 at 10:25 AM, the Assistant Director of Nursing stated personal hygiene consisted of oral care, bathing, dressing, nail care, and shaving. They stated personal hygiene should be offered and completed daily for each resident. The electronic documentation system only asked certified nurse aides if all care was completed, and they would answer yes or no. If a resident refused care, they should notify the nurse so they could reapproach the resident. It was important for the certified nurse aides to offer shaving whenever Resident #43 had facial hair to boost their self-esteem and to maintain their dignity. 2) Resident #15 had diagnoses including dementia, weakness, and need for assistance with personal care. The 6/30/2024 Minimum Data Set assessment documented the resident required modified independence for daily decision making, did not refuse care, and required maximum assistance for hygiene care. The comprehensive care plan initiated 3/4/2021 documented the resident required assistance with activities of daily living and was at risk for impaired skin integrity. Interventions included keep fingernails short to prevent scratches, showers on Tuesday and Friday evenings, and substantial assistance of one for personal hygiene tasks. The September 2024 Documentation Survey Report documented the resident received a shower on 9/24/2024 (Tuesday) by Certified Nurse Aide #25. There was no documentation the resident received a shower on 9/20/2024 (Friday). Resident #15 was observed in their room with long, jagged nails with brown debris and unkempt, matted hair on 9/23/2024 at 11:14 AM, 9/24/2024 at 8:34 AM, and 9/25/2024 at 9:08 AM. The resident stated their nails were too long, their hair had not been washed in 2 weeks, and they did not receive a shower on 9/24/2024. During an interview on 9/25/2024 at 11:13 AM, Certified Nurse Aide #25 stated showers were given twice a week and were documented in the bathing task. Bed baths were given in place of a shower if a resident requested. Hair washing was included in both showers and bed baths. If the shower task documentation stated yes then it meant a shower was given which included hair washing. Nail care was provided whenever needed and could be performed by aides if the resident was not a diabetic. Hair combing was completed every day. Any refusal of care was reported to the nurse. They gave Resident #15 a bed bath last evening at the resident's request but did not wash their hair because they received a bed bath and not a shower. They did not report to the nurse that hair washing was not completed. If residents did not receive their showers or have their hair washed it could cause that resident to feel uncomfortable, moody, or grumpy. Nail care was important because dirty nails could spread bacteria which could cause illness. During an interview on 9/25/2024 at 1:00 PM, Licensed Practical Nurse #6 stated residents received showers twice a week that included hair washing and nail care. Certified nurse aides should provide nail care anytime there was a need unless the resident was a brittle diabetic. Daily morning care should include hair combing. Any refusals of showers, nail care, or hair care should be reported to and documented by the nurse. Resident #15 usually received a shower or a bed bath. They had not noticed the resident's nails, but they should be clean and not jagged. No one had reported to them that Resident #15 refused any care. During an interview on 9/26/2024 at 10:08 AM, Licensed Practical Nurse Manager #22 stated they expected showers were given according to the shower schedule and included nail care and hair washing. If a bed bath was given, hair should still be washed. Nail care was done anytime they were long, jagged or debris was present, and hair combing was provided daily. Resident #15 required substantial assistance with hygiene care. If a shower was signed for by the aide, then it implied that hair was washed as well. During an interview on 9/26/2024 at 10:25 AM, the Assistant Director of Nursing stated showers were provided twice a week and were documented by the certified nurse aides in the electronic record. Personal care included nail care and should be offered daily. It was important to clean and clip nails whenever they were dirty or long to prevent cuts and infections. If nail care or hair care was needed, it should not wait until shower days to be provided. Residents should not have greasy hair and should be offered to have hair washed even if it was not their shower day. Not providing good hygiene could be a dignity and self-esteem issue. 10NYCRR 415.12(a)(3) 50561

Based on observation, record review, and interviews during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #178) reviewed. Specifically, Resident #178's urinary catheter (tube that drains urine) drainage bag was observed above the level of the bladder. Findings include: The facility policy, Urinary Catheter Guidelines, revised 9/11/2023, documented care was provided to residents with indwelling urinary catheters to prevent, reduce the reoccurrence, manage, and resolve urinary tract infections. The urinary catheter drainage bag should be positioned below the level of the bladder and should not touch the floor. Resident #178 had diagnoses including urinary tract infections and chronic kidney disease. The 9/19/2024 Minimum Data Set assessment documented the resident was cognitively intact, had an indwelling urinary catheter, and had a urinary tract infection within the last 30 days. The comprehensive care plan initiated on 9/14/2024 documented the resident had an indwelling urinary catheter. Interventions included maintaining the urinary drainage bag below the level of the bladder, monitor/record/report signs and symptoms of a urinary tract infection, change catheter as ordered, and urology consult as ordered. The 9/12/2024 physician orders documented: - Ciprofloxacin (antibiotic) 500 milligram, 1 tablet daily for 5 days for urinary tract infection. - Indwelling urinary catheter: size16 with a 5-milliliter balloon to down drain, change as needed. The following observations of Resident #178 were made: - on 9/24/2024 at 11:13 AM, 12:31 PM, and 12:43 PM sitting in their wheelchair in their room. Their urinary catheter tubing was observed coming out of the bottom of their left pant leg, under the wheelchair, and the drainage bag was clipped to the top of the wheelchair's backrest that was level with the resident's shoulders and above the bladder. At 12:59 PM, self-propelling their wheelchair down the hallway. The urinary catheter drainage bag was clipped to the bottom of the wheelchair. The resident stated one of the nurses approached them a few minutes ago, moved the drainage bag to the bottom of the wheelchair, and told them it should not have been put on the back of the wheelchair. During an interview on 9/25/2024 at 1:26 PM, Certified Nurse Aide #35 stated urinary catheter bags should always be clipped to the side of the bed or the bottom of a wheelchair. They stated the resident was self-propelling their wheelchair in the hallway when they noticed their catheter drainage bag was clipped to the top of the wheelchair's backrest. They moved it to the bottom of the wheelchair so the urine would be able to flow better. They stated catheter drainage bags should always be placed below the level of the bladder so the urine would not backup in the tubing and cause an infection. During an interview on 9/26/2024 at 9:17 AM, Licensed Practical Nurse #20 stated they noticed Resident #178's catheter drainage bag dragging on the floor under their wheelchair on 9/24/2024, so they moved it to the top of the wheelchair's backrest. They stated they forgot to move it back because they got busy, and by the time they remembered someone had already moved it to the bottom of the wheelchair. They stated it was important to keep catheter drainage bags below the level of the bladder to prevent backflow and urinary tract infections. During an interview on 9/26/2024 at 10:25 AM, Assistance Director of Nursing #3 stated urinary catheter drainage bags should be hung on the side of the bedframe or on the bottom of a wheelchair. They stated it was important for Resident #178's catheter drainage bag to be below the level of the bladder to prevent urinary tract infections. 10 NYCRR 415.12

Based on observation, record review, and interviews during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standard of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 2 residents (Residents #66 and #369) reviewed. Specifically, Resident #66 developed three facility acquired pressure ulcers, one vascular wound (caused by poor blood circulation) and had a low loss air mattress (specialty mattress used to relieve pressure and provide airflow) that was not accurately set to the resident's weight, and the resident was not turned and repositioned as care planned. Resident #379 had a foot wound and did not have their foot offloaded as planned. Findings include: The facility policy, Support Surfaces- Air mattress, created 2/2019, documented the facility provided an environment of care that promoted the highest quality of care and comfort for the residents. This included the treatment and prevention of pressure ulcers with the use of support surfaces. The motor was set to the appropriate settings per the resident assessment. For example, weight for weight. Depending on mattress type, a turning and repositioning schedule was determined. The facility policy, Skin and Pressure Injury Prevention, revised 6/27/2024, documented the facility assessed residents for risk in the development of pressure injuries and implemented preventative measures in accordance with current standards of practice. Once the assessment was conducted and risk factors were identified and characterized, a resident-centered care plan was developed and addressed the modifiable risks for pressure injuries and skin protection interventions. For a person in bed, position was changed frequently, and a pressure relieving/ redistribution device was on the bed. When in bed, every attempt was made to off load pressure to heels and interventions included placement of pillows, heel boots, or other devices as recommended by provider. 1) Resident #66 had diagnoses including hemiplegia and hemiparesis (weakness or paralysis of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, osteomyelitis (bone infection) of the sacrococcygeal (tailbone) region, and severe protein-calorie malnutrition. The 9/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had upper extremity impairment on one side, lower extremity impairment on both sides, was dependent for assistance with toileting, bathing, dressing, bed mobility, and transfers, was at risk for developing pressure ulcers, had 4 unstageable (full thickness, depth unknown) pressure ulcers that were not present on admission, received daily pressure ulcer care, applications of ointments/ medications other than to feet, had a pressure relieving device for the bed, and did not reject care. The Comprehensive Care Plan initiated 4/26/2024 documented the resident had alteration in skin integrity with an actual unstageable pressure injury to the sacrum and left buttocks and a vascular wound to the left lower extremity. Interventions included weekly wound evaluations, dressings were monitored to ensure they were clean, dry, and intact, and the wound was monitored for changes and signs/ symptoms of infection. There were no documented interventions for pressure relief. The undated care instructions documented the resident was provided with a pressure relieving/ redistribution device on the bed and the resident was dependent on one to turn and reposition every 1-2 hours as indicated and as needed. The 8/20/2024 physician orders documented low loss air mattress: check setting closest to resident's current weight and mattress functionality every shift. The 9/18/2024 Nurse Practitioner #38 progress note documented the resident was being seen as requested by nursing to evaluate their wounds. The left posterior leg vascular wound measured 5.0 centimeters x 3.2 centimeters with a pink base. The sacrum wound with undermining measured 12.1 centimeters x 10 centimeter x 4 centimeters. The new unstageable left buttocks ulcer measured 1.2 centimeters x 1.1 centimeters with 100 percent yellow base. There was also a left buttock skin abrasion, no measurements were documented. Interventions included continued use of an air mattress and signs and symptoms of wound infection were monitored. Pressure ulcers were unavoidable as the resident was comfort care, bed bound, and had poor nutrition. The 9/25/2024 Registered Nurse #39 weekly wound evaluation documented the wounds were evaluated by the wound care provider and refer to the wound care provider documentation. Interventions included turning and repositioning, heels off loaded with pillow or heel boots, and pressure relieving/ reducing device on bed. The 9/25/2024 Nurse Practitioner #38 progress note documented the resident was being seen as requested by nursing to evaluate their wounds. The left posterior leg vascular wound measured 5.3 centimeters x 3 centimeters with a pink base. The sacrum wound with undermining measured 9 centimeters x 10.4 centimeters x 2 centimeters with 2 centimeter undermining at 7 o'clock. The unstageable left buttocks ulcer measured 0.5 centimeters x 1.1 centimeters with 100 percent yellow base. The left buttock skin abrasion measured 1 centimeter x 1 centimeter. Pressure ulcers were unavoidable as the resident was comfort care, bed bound, and had poor nutrition. The September 2024 Certified Nurse Aide activities of daily living tasks did not document the resident was turned and repositioned during their shift on 9/1/2024 day shift, 9/4/2024 night shift, 9/5/2024 day shift, 9/15/2024 night shift, 9/17/2024 day shift, and 9/18/2024 night shift. The resident's medical record contained no documentation for the appropriate settings for the pressure relieving air mattress. The Weights and Vital Summary Report documented the resident was not weighed on 9/4/2024 comfort measures-no weights. The last documented weight was 123 pounds on 8/14/2024. Resident #66 was observed; - On 9/23/2024 at 10:29 AM, 12:19 PM, and 2:08 PM, lying in bed with the low air loss mattress set to 380 pounds with the mattress pump upside down on the floor under the bed. - On 9/24/2024 during a continuous observation from 9:07 AM until 11:11 AM, lying in bed with the low air loss air mattress set to 380 pounds with the pump upside down on the floor under the bed. At 1:03 PM the low air loss mattress was set to 230 pounds. - On 9/25/2024 at 9:07 AM, lying in bed with the low air loss mattress set to 230 pounds, the pump was on the foot end of the bed with a pillow over it. At 12:03 PM, 1:19 PM, and 3:28 PM, lying in bed with the low air loss mattress set to 230 pounds and signed as checked by Licensed Practical Nurse #14. - On 9/26/2024 at 9:25 AM, sleeping in bed on their back with the low air loss mattress set to 230 pounds with the pump on the foot end of the bed. During an interview on 9/25/2024 at 1:03 PM, Certified Nurse Aide #15 stated the care instructions told them the frequency a resident needed to be turned and repositioned. The documentation did not include the frequency of turning and repositioning, just that it was completed on their shift. If there was a refusal, it would be documented as a refusal. Turning and repositioning meant they rotated what side the resident was lying on and was important for skin breakdown and discomfort. Resident #66 had wounds and it was important they were repositioned every 2 hours. The air mattress was set by the nurse per the resident's weight. During an interview on 9/26/2024 at 9:27 AM, Certified Nurse Aide #41 stated residents were turned and repositioned every few hours. This meant the resident was in different positions for wound prevention, to keep off pressure points or for wound improvement if wounds were already present. Turning and repositioning meant residents were rotated from side to back and then to the other side. Resident #66 was supposed to be repositioned every 2 hours as they had wounds. They tried to reposition the resident as often as possible, but it was often difficult due to staffing shortages so they just did the best they could. The air mattress was set to the resident's weight but as a certified nurse aide, they did not touch or even look at the settings. They reported it to the nurse if the mattress was not inflated or they noticed a problem with it. During an interview on 9/26/2024 at 9:35 AM, Licensed Practical Nurse #28 stated air mattresses were set to the weight of the resident. The setting was checked at least once per shift. They did not think it was documented anywhere. Documentation meant the settings were checked. If a resident was no longer being weighed, they would not know what the mattress should be set to. They just pushed down on Resident #66's mattress and adjusted the dial per their feeling of too soft or too hard. Resident #66 was tiny, 300 pounds was probably too hard for them, and they were not sure if the mattress set inappropriately could lead to worsening pressure. They thought if the air mattress was set to the resident's weight it would be too soft. They adjusted the setting to 180 pounds a couple days ago by going with their gut. The pump was currently set at 210ish, was missing clips to hang it on the bed frame, and it should not be in the resident's bed. They did not think the weight setting was important, just what the mattress felt like to touch. The low-pressure light was blinking so they would have to have maintenance look at it. They confirmed the air mattress was documented in the Treatment Administration record but just that the air mattress existed, not what setting they set it to. During an interview on 9/26/2024 at 10:19 AM, Licensed Practical Nurse Unit Manager #22 stated turning and repositioning meant the resident was rotated from left side to right or to their back. The purpose was to prevent skin breakdown or worsening breakdown. It was documented per shift and if it was documented, it was expected it was done at the frequency indicated on the care instructions. If a resident had an air mattress, they needed an order for it and part of the order was the setting and to check functionality. If the air mattress was not set to the resident's weight it should be fixed. Resident #66 was comfort measures only and it should be set closest to the weight last documented. Nurses should not be self-selecting settings based upon whether they thought the mattress was too hard or too soft. The resident's last documented weight was 123 pounds on 8/14/2024 and their air mattress set at 380 pounds could make their pressure worse. During an interview on 9/26/2024 at 11:28 AM, the Assistant Director of Nursing stated the certified nurse aides documented turning and repositioning every shift, not every occurrence. There was no way of knowing if the resident was turned and repositioned as care planned because there was no way to document it. It was also not known when the next turn and reposition was due. It was important for frequent turning and repositioning for wound healing and could make the wound worse if not done. Air mattresses were set to the resident's closest weight. It was important it was set appropriately so the resident did not sink into the mattress, or the mattress was not too hard. It was documented by the nurses in the Treatment Administration Record every shift. If it was documented, it meant the settings were verified and if it was not documented, it was not checked. Resident #66 had pressure sores and should be turned and repositioned. The resident's last documented weight was 123 pounds and if their air mattress was set to 380 pounds it would not help with wound healing, they would be on a very hard surface. Nurses were expected to follow orders, they had recently done a training on air mattresses. Nurses were expected to look at the dial and adjust accordingly, pushing on the air mattress was not an appropriate way to set the dial. Resident #66 would not be on their back all day if they were appropriately turned and repositioned. 2) Resident #379 had diagnoses including spinal stenosis (narrowing of the spinal canal), diabetes, and osteomyelitis of the left foot and ankle (bone infection). The Minimum Data Set assessment was not yet completed as the resident was a new admission. The 9/20/2024 at 7:16 PM Registered Nurse #39 Nursing Admission Evaluation documented the resident was admitted to the facility for osteomyelitis of the left foot. The Comprehensive Care Plan dated 9/21/2024 documented Resident #379 was at risk for skin breakdown due to obesity and disease processes. Interventions included skin observations, compression dressing was applied, and adaptive equipment was removed when skin integrity was checked. The undated care instructions documented Resident #379's heels were offloaded with heel boots as tolerated. Resident #379 was observed on 9/24/2024: - at 9:19 AM with a heel bootie hanging from the left side of the bed and their foot resting directly on the bed, the left foot was not offloaded. - at 11:27 AM in bed and the left foot was not offloaded. The boot was on the floor at the end of the bed. The resident stated they wore the boots at home and they made their foot more comfortable. - at 2:43 PM in bed with the boot on the left foot with the foot dangled over the footboard which applied pressure to the left foot. The Certified Nurse Aide Documentation Survey Report documented heel protection: offload with pillow/heel boots/heel suspension boots as tolerated and was completed every shift on 9/24/2024 and 9/25/2024. During an interview on 9/25/2024 at 8:40 AM, Certified Nurse Aide #37 stated Resident #379 came into the facility with a heel boot because they had a wound on their left foot and continued with the heel boot after admission. The heel boot was old, worn, and dirty so they received a new one from physical therapy after admission. If they did not have the heel boot on, the wound could get worse. During an interview on 9/25/2024 at 12:29 PM, Licensed Practical Nurse #31 stated offloading boots removed pressure from areas, prevented wounds from worsening, and provided comfort. They stated Resident #379 was supposed to wear an offloading heel boot to the left foot when they were in bed as they had a wound and required staff assistance to apply the boot. During an interview on 9/25/2024 at 12:53 PM, Licensed Practical Nurse Unit Manager #32 stated care plans were individualized for each resident and completed by a registered nurse on admission. They stated offloading boots were documented on the certified nurse aide instructions. They stated an offloading boot did not require a physician order and could be applied by any nursing staff. They stated if the offloading boot was not worn, the resident could have increased pain and decreased wound healing and Resident #379 had a significant wound. They expected the boot to be on at all times unless the resident refused. Resident #379 did not refuse the boot. During an interview on 9/26/2024 at 10:54 AM, the Assistant Director of Nursing #3 stated care plans were individualized for each resident and ensured the care needs for each resident were met. They did not expect heel boots to be hanging over the bed or on the floor. If the boot was not worn the resident could have decreased healing to a wound or a worsening wound. They stated Resident #379 utilized an offloading left heel boot. 10NYCRR 415.12(c)(1)

Based on observation, record review, and interviews, during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 2 of 2 residents (Resident #7 and #15) reviewed. Specifically, Residents #15 and #7 resting palm (hand) guards were not applied appropriately as recommended by occupational therapy for hand and finger contractures (shortening of muscle or tendons preventing normal movement). Findings include: The facility policy, Appliances- Splints, Braces, Slings, revised 4/2019 documented to protect the safety and well-being of residents, and to promote quality care, the facility used appropriate techniques and devices for appliances, splints, braces, and slings; nursing would ensure certified nurse aide staff knew the proper application and removal of appliances; and nursing would ensure the appropriate sign off of appliance task options. 1) Resident #15 had diagnoses including dementia, weakness, and need for assistance with personal care. The 6/30/2024 Minimum Data Set documented the resident had impaired cognition, functional limitation of the upper extremity, did not refuse care, and required maximum assistance for most activities of daily living. The Comprehensive Care Plan initiated 3/4/2021 documented the resident had limited physical mobility related to gait and mobility abnormalities. Interventions included a left palm protector on at all times except during functional tasks. The resident's Kardex (care instructions) documented left palm protector on at all times except for functional tasks. The 7/30/2024 Occupational Therapy Evaluation and Plan of Treatment by Occupational Therapist #13 documented Resident #15 had a left-hand contracture and during prior therapy sessions from 6/12/2024-7/3/2024 the resident received services to decrease the contracture in their left hand that included a palm protector splint. The resident was observed in their room without a left palm protector on 9/23/2024 at 11:14 AM, 9/24/2024 at 8:34 AM, 9/24/2024 at 12:48 PM, and 9/25/2024 at 9:08 AM. During an interview on 9/25/2024 at 11:13 AM, Certified Nurse Aide #25 stated certified nurse aides applied splints and documented in the task section of the electronic record. If splints were missing or the resident refused, it was reported to the nurse. Resident #15's resident care instructions listed a left palm guard at all times but was not listed as a task they could sign off on. Splints were important to prevent contractures. If a splint or guard was recommended but not used, the resident's contractures could worsen. During an interview on 9/25/2024 at 1:00PM, Licensed Practical Nurse #6 stated certified nurse aides applied splints and if there was a problem applying them it should be reported to the nurse and documented. Splints required an order and were on the treatment administration record for signatures. They were not aware Resident #15 had a recommendation for palm guards. The 9/2024 Treatment Administration Record did not document the use of a palm protector splint. During an interview on 9/25/2024 at 3:13 PM, Licensed Practical Nurse Manager #22 stated therapy evaluated residents for contractures. If a splint was recommended, nursing was informed so the resident's care instructions and care plan could be updated and a task for the aides to document created. Certified nurse aides applied splints and palm guards and any issues or refusals were reported to the nurse and documented. Palm guards were used for hand contractures and should be worn as recommended. If not, open areas, worsening of contractures, and pain could occur. Resident #15 had contractures of their hands and should have a left palm guard on at all times except during functional tasks. This was listed on the resident's care instructions and as a task, however, the task did not allow the certified nurse aides to sign off on. During an interview on 9/26/2024 at 9:14 AM, Physical Therapist #23 stated the therapy department evaluated residents and when splints were recommended, they informed nursing so the care plan could be updated. They expected their recommendations to be implemented and any issues should be reported to them. Resident #15 had hand contractures and a hand guard was recommended. Palm guards were effective in maintaining current range of motion, keeping hands clean, and preventing skin integrity issues that could be caused by fingernails coming into contact with palms. During an interview on 9/26/2024 at 11:42 AM, the Director of Nursing stated therapy made recommendations for splints and palm guards and anyone who had a recommendation should have a task associated with the splints allowing the certified nurse aides to document in the electronic record. Any refusals should be reported to nursing to verify and document. Resident #15 had a left palm guard listed in their care instructions and as a task, however the task had not been activated properly resulting in the certified nurse aides being able to see the task, but not being able to document the task. They felt staff should have asked and verified whether the guards should be put on or not. If palm guards were not applied per recommendations contractures could worsen and skin breakdown could occur. 2) Resident #7 had diagnoses including dementia and Huntington's disease (a progressive neurological disease). The 7/17/2024 Minimum Data Set documented the resident had severe cognitive impairment, did not refuse care, had functional limitation in range of motion in both arms, and was dependent for most activities of daily living. The Comprehensive Care Plan initiated 4/26/2021 documented the resident had limited physical mobility related to deconditioning, Huntington's disease, and functional quadriplegia (inability to move arms and legs). Interventions included bilateral palm guards at all times except during hygiene care. The 10/16/2023 Occupational Therapy Evaluation and Plan of Treatment by Occupational Therapist #13 documented Resident #7 had impaired range of motion in the wrists, hands, and all fingers and recommended that finger separators and a [NAME] guard was worn on both hands at all times except during bathing and exercise. The 11/3/2023 Occupational Therapy Discharge Summary by Occupational Therapist #13 documented the resident's goal of maintaining tolerance for bilateral palm protectors 24 hours a day with periodic skin assessment was met on 10/27/2023. Resident #7's Kardex (care instructions) documented bilateral palm guards on at all times, remove for hygiene. Resident #7 was observed in their room without palm guards on their right and left hands on 9/23/2024 at 11:08 AM, 9/24/2024 at 8:34 AM, and 9/24/2024 at 1:29 PM. During an interview on 9/25/2024 at 11:13AM, Certified Nurse Aide #25 stated Resident #7 had contractures but did not believe the resident wore splints because they had never seen the resident with them. The resident's care instructions included bilateral palm guard at all times but was not listed as a task for the aides to sign for. During an interview on 9/25/2024 at 1:00PM, Licensed Practical Nurse #6 stated they were not aware Resident #7 had a recommendation for palm guards. During an interview on 9/25/2024 at 3:13 PM, Licensed Practical Nurse Manager #22 stated Resident #7 was very stiff and had bilateral palm guards listed in their care plan, in their resident care instructions, and as a task. The task did not allow the certified nurse aides to document in the electronic record. During an interview on 9/26/2024 at 9:14 AM, Physical Therapist #23 stated Resident #7 had hand contractures and palm guards were recommended. The only compliance issue they were aware of occurred 3 months ago when the guards were reported missing and was resolved when they were found in the laundry. During an interview on 9/26/2024 at 11:42 AM, the Director of Nursing stated Resident #7 had hand contractures and bilateral palm guards listed in their care instructions and as a task, however the task had not been activated properly resulting in the certified nurse aides being able to see the task, but not being able to document the task. Staff should have asked and verified whether the guards should be put on or not. Residents that were ordered palm guards and did not wear them could have worsening of contractures and skin breakdown. 10NYCRR 415.12(e)(2)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00321293 and NY00321801) surveys conducted 9/23/2024-9/26/2024, the facility did not ensure each resident received adequate supervision for 1 of 2 residents (Resident #1) reviewed for falls. Specifically, Resident #1 was transferred without the use of a lift device as planned. The facility policy, Therapy Services, created 10/12/2021, documented therapy services would conduct a comprehensive patient centered evaluation which included the development of a plan of care with appropriate interventions to reach specified resident goals. The facility policy, Lift-Full Body Mechanical Lift, last reviewed 8/20/2023, documented at a minimum, two trained staff members were needed to safely move a resident with a floor based full body mechanical lift. Resident #1 had diagnoses included a left femur (thigh bone) fracture and frequent falls. The 8/2/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent on staff for all transfers, and had one fall. The comprehensive care plan initiated 7/7/2021 documented the resident required assistance with activities of daily living and was at risk for falls. Interventions included use of a sit to stand mechanical lift for all transfers. The 6/28/2024 Physical Therapist #12 Physical Therapy Discharge Summary documented the resident used the stand pivot disc for bed to wheelchair transfers. The Kardex (care instructions) documented the resident required a sit to stand mechanical lift for transfers. During an observation on 9/24/2024 at 2:00 PM Resident #1 was in their wheelchair in their room calling out for assistance. Certified Nurse Aide #24 stopped outside their door and asked the resident what they needed. When the resident stated they needed to be changed, Certified Nurse Aide #24 entered the room without any lift device and closed the door. At 2:06 PM, Certified Nurse Aide #24 exited room without a lift and the resident was lying in their bed. There was no lift device observed in the resident's room. During an observation on 9/25/2024 at 10:50 AM a lift device was not observed in Resident #1's room. Resident #1's visitor informed Licensed Practical Nurse #6 the resident was sitting in their wheelchair and needed to be changed. Licensed Practical Nurse #6 asked for the assistance of a certified nurse aide. Both Licensed Practical Nurse #6 and the certified nurse aide entered the room without a lift device. At 10:57 AM, Licensed Practical Nurse #6 brought the resident out of their room in their wheelchair followed by the certified nurse aide. Neither brought a lift device out of the room and there was not one observed in the resident's room. During an observation on 9/25/2024 at 12:52 PM, a visitor returned Resident #1 to their room in their wheelchair. At 1:30 PM the resident's family requested the resident be changed. Certified Nurse Aide #15 entered the resident's room without a lift device. The resident was in bed, Certified Nurse Aide #15 was in the bathroom, and there was no lift device in the room. During an interview on 9/24/2024 at 2:27 PM, Certified Nurse Aide #24 stated the transfer status of a resident was found in the computer kiosk and was checked every shift before they started working. A mechanical lift transfer always required the assistance of two staff for safety of the residents and to prevent falls. One person was needed to hold the lift and the other to hold the resident. Staff should only transfer residents according to what was documented on their care instructions. Resident #1 was independent with transfers a couple months ago, but after a fall and a broken hip they were changed to assist of 1 for transfers. During an interview on 9/25/2024 at 10:20AM, Resident #1 stated staff did not use a lift device to transfer them in and out of bed but used the resident's arms to transfer. During an interview on 9/25/2024 at 1:00 PM, Licensed Practical Nurse #6 stated resident's transfer status was documented in the care plan and on the task list. Therapy determined the transfer status of the residents. Transfer status was checked every day for changes and should always be followed. If a recommendation was for a sit to stand, it would not be appropriate to transfer a resident without the use of it. The facility had Hoyer lifts (a brand of a mechanical lift) and a mechanical sit to stand. The use of any lifting device required the assistance of two people. Resident #1 required assistance of two to stand pivot transfer, but a lift could be used if the resident was having difficulty. It was important that therapy's transfer recommendations were followed as the resident and staff could get hurt. During an interview on 9/25/2024 at 3:13 PM, Licensed Practical Nurse Manager #22 stated therapy determined a resident's transfer status. Those recommendations were communicated to nursing, who then updated the care tasks and care instructions. They expected the nurse aides to check the care instructions every time prior to the start of their shift. The facility had a Hoyer and a stand pivot disc, but not a mechanical sit to stand. All three devices required the assistance of two when used. Staff was allowed to use more assistance than required in the care plan, however, could not use less assistance than was documented in the care plan. Resident #1's therapy recommendation from 4/19/2024, indicated the resident required the use of a mechanical sit to stand lift. There was a handwritten notation to use stand pivot disc for transfers. Staff should use the stand pivot disk when transferring the resident. If therapy recommendations were not followed a resident could be injured. During an interview on 9/26/2024 at 9:14 AM, Physical Therapist #23 stated the facility currently used Hoyer lifts and a stand pivot disc. There was a mechanical sit to stand that was not functioning and had been in the basement for about six months. The mechanical sit to stand provided more assistance to the resident than the stand pivot disc. The stand pivot disk could be used on the unit by the certified nurse aides and required the assistance of 1 or 2 people and a gait belt. Physical therapy's transfer recommendations should be followed to provide consistency and to prevent falls or injuries. Resident #1 once used a four wheeled walker, but after a fall, therapy's recommendation changed to stand pivot disc with gait belt assistance of two. There had been no recent changes in the resident's status that had been reported to them and it was not safe to transfer the resident with assistance of one. During an interview on 9/26/2024 at 11:42 AM, the Director of Nursing stated transfer status was in the care plan and care instructions and should always be followed unless changed by therapy. The facility had Hoyer lifts and a stand pivot disk and staff were educated on their use. There was not a mechanical stand lift in the building. The stand pivot disk required assistance of two and provided less support than the mechanical sit to stand. The two were not interchangeable. Resident #1's had a history of falls and their care task stated they were a mechanical lift sit to stand however, the clarified instructions documented a stand pivot disc. They expected staff to verify this because the mechanical sit to stand lift was not available. If the resident was care planned for a lift device, staff should be using it. It was not okay to transfer the resident with assistance of one or without the recommended device as falls, shoulder injuries, and staff injuries could occur. 10 NYCRR 415.12(h)(1)(2)

Based on observation, record review, and interviews during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for 1 of 1 resident (Resident #17) reviewed. Specifically, Resident #17 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments. Additionally, staff documented the resident had an arteriovenous fistula (surgical connection between an artery and a vein often used for dialysis access) which the resident did not have. Findings include: The facility policy, Dialysis Access Care, revised 5/2019, documented the central catheter (a tube inserted into a large, central vein) site was kept clean and dry at all times and bathing and showering were not permitted with this device. Catheter lumens (outside ends of the catheter) were capped and clamped when not in use. The general medical nurse documented in the resident's medical record every shift the location of the catheter, condition of the dressing, if dialysis was done during the shift, and any report from dialysis nurse post-dialysis and observations post dialysis. The facility policy, Dialysis Management, revised 5/2019, documented residents that received hemodialysis treatments were assessed and monitored and ensured quality of life and well-being. The access site was observed for function and signs and symptoms of infection. Orders were obtained for monitoring of the site and interventions as appropriate. Permacaths (a central catheter used for long-term access) were observed for bleeding and placement. The nurse would evaluate the resident post dialysis for access site condition and document in the nurse's notes. Resident #17 had diagnoses including end stage renal (kidney) disease, dependence on renal dialysis, and cerebral infarction (stroke). The 7/19/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, had end stage renal disease, and required hemodialysis treatments. The Comprehensive Care Plan initiated 5/22/2024 documented the resident needed hemodialysis related to end stage renal disease. Interventions included the check the access site dressing daily; change dressing only if ordered by the physician; document condition and complications; monitor for signs of infection such as redness, swelling, warmth, or drainage and document; and monitor the Permacath to the right upper chest for bleeding and placement. The resident received dialysis on Monday, Wednesday, and Friday with a 6:00 AM pick up time and a 7:00 AM chair time. The 8/12/2024 physician order documented monitor the Permacath for bleeding and placement every shift. If bleeding was noted, pressure was to be applied, and the physician was to be notified. If dislodged, pressure was applied and 911 was to be called. The order did not specify the location of the Permacath. The dialysis communication book documented the resident attended dialysis on 9/2/2024, 9/4/2024, 9/6/2024, 9/9/2024, 9/11/2024, 9/13/2024, 9/16/2024, 9/18/2024, 9/20/2024, 9/23/2024 and 9/25/2024. There was no documented evidence of pre-dialysis evaluations on 9/2/2024, 9/13/2024, 9/18/2024, 9/20/2024, and 9/23/2024. There was no documented evidence of post-dialysis evaluations on 9/4/2024, 9/6/2024, 9/13/2024, and 9/20/2024. During an observation and interview on 9/23/2024 at 12:21 PM, Resident #17 stated they attended dialysis on Monday, Wednesday, and Friday at a community-based dialysis center and they had just gotten back. The resident had a right chest dual lumen Permacath for dialysis covered with a white dressing that was clean, dry, and intact. They did not recall if the facility obtained vital signs or weights before or after dialysis treatments. There was a binder that went with them back and forth from dialysis. The 9/23/2024 Licensed Practical Nurse #28 post dialysis evaluation documented the resident had a Permacath and their arteriovenous fistula bruit (swooshing sound that indicates the fistula is working) was audible, and thrill (a vibration that can be felt when placing fingers over the arteriovenous fistula indicating blood flow) was present. No site changes of the arteriovenous fistula. There was no documented evidence in the resident's medical record of an arteriovenous fistula. The 9/25/2024 Licensed Practical Nurse #14 post dialysis evaluation documented the resident had a Permacath and the arteriovenous bruit was audible, and thrill was present. No site changes of the arteriovenous fistula. During an interview on 9/25/2024 at 1:35 PM, Licensed Practical Nurse #14 stated pre and post dialysis assessments were documented electronically. Resident #17 had a Permacath, but they did not remember where their access site was located. They had completed the resident's post dialysis assessment today around 11:30 AM when the resident returned from dialysis. They looked at the access site with that assessment. They checked the electronic medical record and confirmed they completed the post dialysis assessment at 11:37 AM but was not sure where the access site was located. It was important the site was monitored because the resident could bleed out. During an interview on 9/25/2024 at 3:29 PM, Licensed Practical Nurse #28 stated Resident #17 had a Permacath to their left chest for dialysis. The dressing was supposed to be clean, dry, intact and without signs of infection. They were not sure if the site should be monitored for anything else. The pre and post dialysis assessments were documented and if they were not documented, they were not done. During a follow up interview on 9/26/2024 at 9:46 AM, Licensed Practical Nurse #28 stated the resident had a right chest Permacath only and did not have an arteriovenous fistula. They showed the surveyor the electronic charting of the post dialysis note. They documented on an arteriovenous fistula because not applicable was not an option. It was not appropriate to document on an arteriovenous fistula because Resident #17 did not have one. During an interview on 9/26/2024 at 10:35 AM, Licensed Practical Nurse Unit Manager #22 stated pre and post dialysis assessments were completed and contained information about the site appearance and type of access site. An arteriovenous fistula should not be documented if the resident did not have that type of access site. It was important the site was monitored for bleeding and signs of infection. It was also monitored every shift and documented in the Treatment Administration Record and if it was documented, it meant the nurse looked at the site. Resident #17 received dialysis and the site should be monitored. During an interview on 9/26/2024 at 11:18 AM, the Assistant Director of Nursing stated the pre-dialysis assessment documented either a Permacath access site or an arteriovenous fistula. The nursing staff checked the dialysis site for bleeding, if the Permacath was intact, and not pulled out. If it was not documented, it was not done. The site was monitored every shift for displacement, bleeding, and signs of infection. If the site was monitored staff should know where the site was located. Resident #17 received dialysis and had a right chest Permacath. They checked the resident's electronic medical record and the pre and post dialysis assessments were not being consistently done but should have been. It was especially important the site was monitored after dialysis because there could be a medical emergency. It was important that any changes to the site appearance or the resident's vital signs were communicated to dialysis and without the appropriate assessments, changes were not monitored. 10NYCRR 415.12(k)

Based on observation, record review, and interviews during the recertification survey conducted 9/23/2024-9/26/2024, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 1 resident (Resident #383) reviewed. Specifically, Resident #383 had a physician order for a nectar thick consistency for all liquids and was served thin liquids. Findings include: The facility policy, Modified Food Consistency Policy, reviewed 2/2023, documented diets were individualized with modifications made by the speech/language pathologist and physician in conjunction with the registered dietitian or designee and Director of Food Services. A written order was required. The food and nutritional services department was responsible for preparing and serving the diet texture and fluid consistency as ordered. The facility diet manual documented nectar thick liquids consistency was syrup like and coated a spoon. Resident #383 had diagnosis of Parkinson's disease (a progressive neurological disease) and dysphagia (difficulty swallowing). The resident was admitted during the evening on 9/23/2024. The 9/23/2024 hospital discharge summary documented Resident #383 was evaluated by a speech language pathologist for ongoing dysphagia which was present prior to admission. The resident was mostly nonverbal at baseline secondary to Parkinson's disease and a traumatic subdural hematoma (collection of blood between the brain and skull) following a fall in February 2024. The resident underwent a modified barium swallow study (evaluates swallowing ability) on 9/23/2024 which showed moderately severe oropharyngeal dysphagia consistent with Parkinson's disease. Their swallow was severely delayed, and their pharyngeal musculature was very weak. It was recommended to continue a pureed and nectar thick diet. The physician #9 9/23/2024 admission orders documented a heart healthy puree texture and nectar thick consistency diet. During an observation on 9/24/2024 at 8:24 AM, Resident #383 was in their room in bed with their breakfast tray. Their family member asked Physical Therapist #17 who was in the hall, why Resident #383 had thin liquids when they had nectar thick liquids in the hospital until their discharge yesterday evening. Physical Therapist #17 stated they would look into it and get back to the family member. The meal ticket documented a pureed diet only. There was no documentation of nectar thick liquids. Physical Therapist #17 returned and stated they checked with the nurse and Resident #383 was ordered nectar thick liquids and they removed all the thin liquids from the resident's tray before the resident drank. The resident's breakfast meal ticket dated 9/24/2024 documented nectar thick orange juice, nectar thick skim milk, nectar thick coffee, and nectar thick water. During an interview on 9/24/2024 at 8:56 AM, Resident #383's family member stated the resident was in the hospital following a tractor rollover, they were recovering from multiple broken bones, and they underwent a swallowing evaluation before being admitted to the facility. After the swallowing evaluation the family member was told Resident #383 was silently aspirating (inhaling food or liquids in the lungs). They visited the resident last evening after dinner was served and did not observe the meal served to the resident. During an interview on 9/24/2024 at 9:40 AM, Certified Nurse Aide #30 stated the wrong tray was given to Resident #383 that morning. During an interview on 9/25/2024 at 12:29 PM, Licensed Practical Nurse #31 stated when there was a new admission, orders were sent from the hospital to the facility for review and the orders were entered before the resident arrived. Orders were entered by the admitting licensed practical nurse which included diet orders. After the diet was ordered they thought the order went to the kitchen and the registered dietitian, and the meal ticket was printed by the front desk attendant and given to the kitchen staff. During an interview on 9/25/2024 at 12:53 PM, Licensed Practical Nurse Unit Manager #32 stated they were notified of the pending admissions every morning. The hospital called report to the unit nurse and the admission assessment was completed by them or the unit licensed practical nurse and a diet was ordered. Director of Food Services #33 picked up the diet order and ensured each resident received the correct diet. They stated Resident #383 arrived at the facility on 9/23/2024 at approximately 5:00 PM and was ordered a pureed nectar thick diet because they had swallowing problems at the hospital. They were unsure what diet consistency Resident #383 received for dinner on 9/23/202 or how the resident received the wrong fluid consistency for breakfast on 9/24/2024. They stated it was important for the resident to get the right consistency because they could choke and get pneumonia. During an interview on 9/25/2024 at 3:16 PM, Physical Therapist #17 stated they were working in the morning on 9/24/2024 when they were notified by a family member that Resident #383 had the wrong fluid consistency on their tray. They looked at the meal ticket which documented regular pureed. If the resident was on nectar thick liquids the meal ticket would document puree/nectar, however the ticket did not document nectar thick liquids. They asked Licensed Practical Nurse #14 who confirmed the resident was ordered nectar thick liquids. Physical Therapist #17 stated they removed all the thin liquids which included coffee, orange juice, and milk from the resident's tray. They stated if a resident received the wrong consistency they could aspirate and get pneumonia. During an interview on 9/26/2024 at 9:30 AM, Food Service Director #33 stated they were notified of new admissions during their morning meeting. After residents arrived at the facility, they were notified by the receptionist in an email. They stated Resident #383 arrived at the facility at approximately 5:00 PM, and there was no diet order in the system, so they asked a nurse on the unit for the diet order. They were unsure what nursed told them the resident was on a pureed diet. They stated the nurse did not tell them the resident was on nectar thick liquids, they did not ask, but they should have. They stated Resident #383 received thin liquids on their 9/23/2024 dinner tray and on their 9/24/2024 breakfast tray. They stated the resident could have choked if they consumed the wrong consistency liquids. During an interview on 9/26/2024 at 10:54 AM, Assistant Director of Nursing #3 stated nurses were responsible for checking the meal ticket to ensure the resident had the correct consistency. They stated they expected all residents to receive the correct consistency on their meal tray and if they did not, the resident could choke and get pneumonia. 10NYCRR 415.14 (d-e)

Based on record review and interview during the abbreviated survey (NY00312672), the facility did not provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 6 residents (Resident #6) reviewed. Specifically, Resident #6 was discharged without a documented discharge plan. Additionally, there were recommendations for equipment and post-discharge services there were not established by the facility prior to discharge. Findings include: The Discharge Planning policy revised 12/2019 documented the facility will develop a comprehensive discharge plan for all residents being discharged . The social worker will be responsible for the duties of discharge coordinator including: - participate in an interdisciplinary team discharge meeting with the resident and/or their representative. - Initiate all necessary referrals for all necessary post-discharge care and needs, including primary care physician, medical equipment, in-home services, transportation, and referral for additional medical follow-ups as needed. - Coordinate all discharge plans with the interdisciplinary team and the resident/representative. - Document the steps taken for discharge planning in the resident's medical record. The Discharge-Transfer/Discharge Process revised 12/2019 documented: - if a resident is being discharged to the community, the social worker, in conjunction with the interdisciplinary team will coordinate all necessary medical, physical, mental, and psychosocial service for the resident to ensure a safe transition to the community. - This includes, but not limited to the arrangement of home health aide services, other needed in-home services, ordering durable medical equipment as needed, and scheduling follow-up appointments with the resident's primary care physician and other medical specialists in the community. - If the resident is being discharge to the community, their Discharge Instructions will include a list of all the resident's medications and dosages, as well as a summary of any treatments/therapies at the facility and will also include the contact information for any services the resident will be receiving in the community. Resident #6 had diagnoses including anxiety disorder, non-pressure chronic ulcer of the left heel and right heel and midfoot, and muscle weakness. The 2/19/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment. There was no documentation in the assessment related to discharge planning. The resident's Face Sheet documented the resident's relative was their healthcare proxy, designated representative, and responsible party. The relative's address was listed and it was not the same as the address noted for the resident. The comprehensive care plan, initiated 2/13/2023, did not contain documentation related to discharge planning. The resident's comprehensive care plan was resolved/discontinued on 3/10/2023 with no updates related to discharge planning. The 2/14/2023 physician's orders documented: - a treatment to the wound on the right heel: cleanse with wound cleanser, pat dry, apply collagen (wound treatment) then alginate AG (antimicrobial treatment), and cover with bordered gauze, every day. - A treatment to the right posterior (back) ankle: cleanse with wound cleanser, pat dry, apply collagen then alginate AG, and cover with an absorbent dressing and wrap with kerlix (gauze wrap). - Medication orders: Melatonin (sleep aid), Pantoprazole sodium (antacid), Trazadone (sleep aid/anti-depressant), and [NAME] external lotion. The 3/7/2023 physician #12's progress note documented the resident's medications included Pantoprazole, Trazadone, [NAME] lotion, and oxycodone (narcotic pain medication). The resident completed short-term rehabilitation, was to continue with current medications and wound care, and was to have follow-up appointments with their primary care provider and wound management. There was no documented evidence an appointment was established for the resident's primary care provider or for a wound care provider. Written prescriptions dated 3/7/2023, signed by physician #12 documented: - home physical and occupational therapy evaluation and treatment, for mobility impairment. - Home health aide, for the diagnosis of mobility impairment, under the diagnosis on the bottom of the prescription was written wound care. There was no documented evidence home health aide or physical/occupational therapy agencies were contacted for referrals. There were no documented social services progress notes in the resident's medical record from 2/13/2023-3/10/2023. There was no documented evidence a discharge planning meeting occurred to identify the resident's discharge needs and discharge plan. The 3/10/2023 occupational therapy discharge summary documented the resident was being discharged to live alone in a private residence. Equipment prior to onset included a standard walker. Discharge recommendations included a two-wheeled walker and offloading heel boot for functional mobility. The 3/10/2023 physical therapy discharge summary documented the resident could walk 250 feet with modified independence (stand-by assistance) using a two-wheeled walker on level surfaces. Discharge recommendations included a rolling walker for all ambulation. There was no documented evidence a two-wheeled walker or offloading heel boot were ordered or obtained for the resident. The 3/10/2023 Discharge Instructions documented: - the discharge date was 3/10/2023 and the discharge location was the resident's home address. - There were no community medical provider or upcoming appointments noted. - There was no home care referral agency or other community referrals documented. - There were no follow-up specialist appointments and no current clinical needs noted (including wound care). - Two medications were listed (pantoprazole and acetaminophen) and were reviewed with the resident. - The resident had a right heel wound, left foot excoriation (reddened areas), and right ankle pressure wound the treatment was reviewed with the resident and/or their representative and the form was electronically signed by registered nurse #9. - There was no documentation related to the pharmacy order for medications, the directions for wound care, or wound care supplies. - In the therapy discharge instructions section, equipment recommended for discharge included a rolling walker and an offloading heel boot, electronically signed by occupational therapist #7. - The resident and registered nurse #9 signed the form, dated 3/10/2023. The 3/10/2023 Transfer/Discharge Notice documented the resident was to be discharged [DATE]; their representative named was their relative/healthcare proxy (medical decision maker); the discharge location was the resident's home address; the resident signed the form, dated 3/10/2023; the representative's signature was noted as unable to sign, and registered nurse #9 signed the form on 3/10/2023. The Trip Confirmation form dated 3/10/2023 documented the resident was to be picked up at the facility at 2:45 PM and transported to an address that was not listed as the resident's home address (per the Face Sheet and discharge instructions). The address shown was noted as the resident's relative's address in the same city. The transportation contact name was medical records staff #10. There was no documented evidence the resident was to be transported to their relative's home upon discharge or of the reason the discharge address was the relative's home. A fax cover sheet, dated 3/14/2023, documented 26 pages were sent to an unidentified (first name only) person, from medical records staff #10 regarding the resident. The pages following the fax cover sheet included facility wound consultant progress notes from 3/7/2023, physician #12's 3/7/2023 progress/discharge note, the 3/7/2023 Discharge Instructions, physician's orders as of 3/10/2023, and 2 written prescriptions dated 3/7/2023, completed by physician #12 for therapy, home health aide, and wound care. During an interview with the Director of Therapy on 2/21/2024 at 12:58 PM, they stated they only use wheeled walkers in the facility. The resident was noted to have a standard walker at home, and that was the reason they did not order a walker for them. They stated a standard walker had no wheels, and the resident would have to pick it up and place it as they walked. The facility did not use walkers without wheels and the Director of Therapy stated they considered the wheeled walkers they used as standard. They had not questioned if the resident's walker had wheels and just assumed it did. The offloading heel boot was to help protect the resident's foot when walking, due to the wound on their heel. The discharge recommendations included the rolling walker and offloading heel boot. The walker was not ordered due to the resident having one at home, and the Director of Therapy was unaware of who would order an offloading heel boot, as the therapy department did not. During an interview with medical records staff #10 on 2/22/2024 at 1:56 PM, they stated when Resident #6 was discharged , the social worker was on leave, and they were asked to help. The medical records staff would sometimes assist the therapy department with ordering medical equipment and they did not order anything for Resident #6. The medical records staff sent the resident records and prescriptions to their primary care provider via fax on 3/14/2023, per their provider's request. They were asked to get the information and referral for the home health care, therapy services, and wound care. The medical records staff was unsure of any agencies or services for the resident due to them residing in another county. They also set up the transportation for the resident when they were discharged . They were unsure of the reason the resident went to their relative's address and could not recall who asked them to use that address. During an interview with the Director of Nursing on 2/23/2024 at 11:21 AM, they stated typically discharge planning involved care plan meetings, identification of discharge goals, and a discharge meeting with the family and/or resident. The discharge meeting would include discussion of any services or equipment needed at home, and if any services were needed in the community. The social worker was responsible for coordination of services needed for discharge. When Resident #6 was discharged , social worker #8 was new in their position, had not worked very much, and left the position within a few weeks. The Director of Nursing was unable to locate any discharge meeting notes where the resident's discharge needs were reviewed. The discharge instructions should include medical provider names and contacts, follow-up appointments, and any agency names and contact numbers for needed services. The Director of Nursing was unaware if the resident's standard walker they had at home was the same as the recommended rolling (wheeled) walker and there was documentation related to this being clarified. The therapy department was responsible to coordinate the order for the recommended offloading heel boot and they typically notified the social worker for the order. The prescriptions for wound care, home health aides, and therapy services were intended to assist the resident in setting up the needed services. The facility typically set up these services and the Director of Nursing was unaware if the family may have stated they would take care of it. There were no agency names or referrals on the discharge instructions for the resident to set up the services in the community. When registered nurse #9 reviewed the discharge instructions, they should have noted if there were any changes, such as in discharge destination or if the family agreed to set up services on their own. The lacking information was not clarified and should have been reviewed upon discharge. 10NYCRR415.11(d)(3)

Based on record review and interview during the abbreviated survey (NY00328705) the facility did not provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 nursing units (South Unit) reviewed. Specifically, the heat stopped working on the South Unit on 11/22/2023 and was not restored until 11/24/2023. During the time the heat was not functional, there was no documented evidence the facility routinely monitored and addressed cold air temperatures and no documented evidence a consistent plan was implemented to ensure resident comfort was maintained. Findings include: On 11/24/2023, a call was received to the nursing home complaint hotline from Resident #1 who reported the heat had been off in their wing for 3 days and they overheard staff say the heat would not be fixed until Monday (11/27/2023). During an interview on 11/26/2023 at 6:45 PM, the Administrator stated the heat stopped working during the evening of 11/23/2023. Maintenance staff tried to fix it and could not so a vendor came onsite and fixed it by mid-afternoon on 11/24/2023. The boiler that controlled the South Unit was affected. The North Unit did not have any issues. The facility's TimeLine of Event completed by the Administrator documented the date of the event was 11/24/2023 and type of event was a Heating Issue - Problem with Boiler - Cold Weather Protocol. The timeline further documented: - on 11/23/2023 after 9 PM, they were made aware there were issues with the heat going on and off. - On 11/23/2023 after 10 PM, a call to the boiler company yielded an automated response Thanksgiving. - On 11/24/2023, 7 AM to 9 AM, monitored temperature. - On 11/24/2023, 9:30 AM and 10:30 AM, worked with Maintenance Assistant #1 and the Corporate Director of Maintenance to try to fix the issue. - On 11/24/2023 at 11:30 AM, call to boiler company who arrived at 1:30 PM. - On 11/24/2023 at 4:30 PM, heat restored on the South Unit. The Air Temperature log (received by the surveyor on 11/28/2023) contained documentation for 11/24/2023 only and documented times hourly from 7 AM through 1 PM. Temperatures were recorded once per hour on the South Unit and ranged from 62.9 Fahrenheit to 66 Fahrenheit and the form was signed by Maintenance Assistant #1. A second copy of the Air Temperature Log (received by the surveyor on 12/8/2023) contained the information sent previously with notations for 11/25/2023 documented below 11/24/2023. On 11/25/2023, temperatures were taken hourly between 7 AM and 3 PM and ranged from 62.3 Fahrenheit to 66.8 Fahrenheit. The form was initialed by Maintenance Assistant #1. During an interview on 12/1/2023 at 9 AM, certified nurse aide #2 stated the heat was not working all day on 11/23/2023. They did not know what the temperature was but it was so cold that they wore a zip up sweatsuit jacket with the hood up while working. The facility ran out of blankets for residents so they went to their car and got 2 blankets to give to residents. The residents complained all day about being freezing. A family member brought in 2 space heaters for a resident but the Administrator stated they could not use them. They stated they worked yesterday and the building was very cold that day. They left yesterday at 2:15 PM to go to an appointment with a resident and it was cold in the building. Most residents had 4-6 blankets on when the heat was out on 11/23/2023. During an interview on 12/1/2023 at 3 PM, licensed practical nurse #3 stated they worked 11 PM to 7 AM on 11/23/2023 into 11/24/2023. On that shift, the facility was cold. The residents were freezing and they ran out of blankets. While working they wore an extra sweatshirt. To their knowledge, no one from management assisted with getting extra blankets for residents but families brought in space heaters and heated blankets. When the heat was out, they heard there was a missing part that would be there 11/27/2023. They stated they worked yesterday and it was cold in the facility yesterday too. During an interview on 12/1/2023 at 5:10 PM, certified nurse aide #4 stated they recalled the heat not working last week and the residents thought it was too cold. They gave residents extra blankets and some had space heaters in their rooms. They did not move any residents out of their rooms and when they came to work 11/24/2023 at night the heat was fixed. During an interview on 12/1/2023 at 5:27 PM, certified nurse aide #5 stated they worked all day on 11/23/2023 and the heat was out all day and it started to go out around 7 PM on 11/22/2023. They noticed it when residents started complaining of being cold. On 11/23/2023, they gave residents extra blankets. The heat was back on fully on 11/24/2023. They used shower blankets for residents and did not move anyone from their rooms. During an interview on 12/6/2023 at 2:09 PM, Maintenance Assistant #1 stated: - the heat started acting up at night on 11/22/2023. - When they came to work in the morning on 11/23/2023, there was no heat. There was an issue with one of the boilers that occurred the night before. A vendor came and serviced the boiler on 11/24/2023. - On 11/23/2023 at 7 AM, they started monitoring temperatures. They only checked temperature when there was an issue and did not do routine checks. - They logged temperatures from 7 AM to 3 PM on 11/23/2023 when then left for the day. They were not aware of anyone monitoring temperatures after they left on 11/23/2023 until the heat was fixed on 11/24/2023. - They thought the lowest temperature they measured on 11/23/2023 was 63 Fahrenheit. - Residents were given blankets and space heaters. The facility had space heaters to give out. - They were not aware of any residents bring moved to an area with heat. During an interview on 12/7/2023 at 4:15 PM, Activity Aide #6 stated they worked 11/22/2023 and the South Unit was cold. The employees such as nurses, aides, and housekeeping complained and reported the problem to maintenance. They were not aware of anyone taking temperatures. They gave blankets to residents who were complaining it was cold. During an interview on 12/8/2023 at 2:45 PM, Maintenance Assistant #1 was asked why the second temperature log provided had temperatures noted on 11/24/2023 and 11/25/2023 when they stated the heat went out on 11/22/2023 and was fixed on 11/24/2023. Maintenance Assistant #1 stated the first set of temperatures written on the top of the form and noted as 11/24/2023 were from 11/23/2023 and the ones on the bottom of the form were from 11/24/2023. On 11/23/2023, they left work at 1 PM so that was when the temperature monitoring was stopped. They checked temperatures on the South Unit in the hallway. They did not check temperatures in any resident rooms. They stated they did not know how the facility was monitoring the temperature in resident rooms during that time period. During an interview on 12/8/2023 at 3:28 M, the Administrator stated: - they were aware of the heat going out on 11/23/2023. - Prior to that they did not take the air conditioner units out of windows and there could have been a draft associated with those units. - The facility did not provided space heaters to residents but some families brought them in. They were evaluated by staff and used for the night, and removed the next day when the heat was restored. - The facility did not routinely monitor air temperatures but did so when there was an issue including in resident rooms. - They found out about the heat not working late at night and then alerted maintenance so they could start taking temperatures. The temperatures started in the morning. 10 NYCRR 415.29 f (6)

Based on record review and interview during the abbreviated survey (NY00328705) the facility did not operate and provide services in compliance with Federal, State, and Local Laws and Professional Standards for 1 of 2 nursing units (South Unit) reviewed. Specifically, the heat stopped working on the South Unit on 11/22/2023 and was not restored until 11/24/2023 and the facility did not report the outage to the New York State Department of Health (NYS DOH) as required. Findings include: On 11/24/2023, a call was received to the nursing home complaint hotline from Resident #1 who reported the heat had been off in their wing for 3 days and they overheard staff say the heat would not be fixed until Monday (11/27/2023). During an interview on 11/26/2023 at 6:45 PM, the Administrator stated the heat stopped working during the evening of 11/23/2023 and it was fixed by mid-afternoon on 11/24/2023 on the South Unit. The facility's TimeLine of Event completed by the Administrator documented the date of the event was 11/24/2023 and type of event was a Heating Issue - Problem with Boiler - Cold Weather Protocol. The timeline further documented: - on 11/23/2023 after 9 PM, they were made aware there were issues with the heat going on and off. - On 11/24/2023 at 4:30 PM, heat restored on the South Unit. The Air Temperature log (received by the surveyor on 11/28/2023) contained documentation for 11/24/2023 only and documented times hourly from 7 AM through 1 PM. Temperatures were recorded once per hour on the South Unit and ranged from 62.9 Fahrenheit to 66 Fahrenheit and the form was signed by Maintenance Assistant #1. During an interview on 12/1/2023 at 5:27 PM, certified nurse aide #5 stated they worked all day on 11/23/2023 and the heat was out all day and it started to go out around 7 PM on 11/22/2023. They noticed it when residents started complaining of being cold. On 11/23/2023, they gave residents extra blankets. The heat was back on fully on 11/24/2023. During an interview on 12/6/2023 at 2:09 PM, Maintenance Assistant #1 stated: - the heat started acting up at night on 11/22/2023. - When they came to work in the morning on 11/23/2023, there was no heat. There was an issue with one of the boilers that occurred the night before. A vendor came and serviced the boiler on 11/24/2023. During an interview on 12/8/2023 at 3:28 M, the Administrator stated they did not report the outage to the NYS DOH. They stated they were aware of the heat going out in the evening on 11/23/2023 and they were getting it fixed on 11/24/2023 but then it was taking longer than expected because it came on and went out again. They stated it should have been reported at that time. 10NYCRR 400.2

Based on interview and record review during an abbreviated survey (NY00306536, NY00293811, NY00292846, and NY00282762), the facility failed to promptly notify the ordering physician or nurse practioner (NP) of laboratory results that fall outside of clinical reference ranges in accordance with facility polices and procedures for notification of a practioner of per the ordering physician's orders for 4 of 4 residents reviewed (Residents #2, 5, 6, and 7). Specifically, Residents #2, 5, 6, and 7 had laboratory values that resulted and there was no documented evidence the medical provider was notified of those results timely. Findings include: The facility policy titled Lab/Test Results- Reporting revised 9/2019 documented the lab would send written results upon completion of the test. The lab would identify any critical values so the nurse would immediately notify the physician. The nurse would call or fax the abnormal results to the physician. When the nurse called or faxed the results to the physician, the nurse would document on lap slip which would include the date, time, and who the results were reported to. 1) Resident #2 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD) and multiple sclerosis. The 10/17/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, and required limited or extensive assistance for most activities of daily living (ADL). The 10/27/22 Laboratory Report documented the resident's potassium was low at 3.1 mEq/L (milliequivalent per liter, normal range 3.6 to 5.0 mEq/L). The resident's white blood cell count (WBC, laboratory level which indicates an infection) was high at 12.9 per microliter (normal 4.2 to 11.0). Licensed practical nurse (LPN) #7 documented on the lab results, 10/31/22 noted. Reported to NP (nurse practioner), who ordered BMP (basic metabolic panel, blood work that checks levels such as potassium) and CBC (complete blood cell count) on 11/1/22, UA/culture (urinalysis and culture, laboratory test that checks for a urinary tract infection). It was okay to straight cath (urine sample obtained by placing a catheter into the bladder). The 10/31/22 at 10:26 PM, LPN #7's progress note documented labs were reported to the NP, new order for BMP and CBC for the next day, and UA due to elevated WBC. The resident was straight catheterized for the urine sample. The 11/1/22 Laboratory Report documented the resident's potassium was low at 3.1 mEq/L. The labs were noted by LPN #7. There was a handwritten note to give KCl (potassium chloride, supplement to replace low potassium levels in the blood) 30 mEq (milliequivalent) daily for 3 days then 10 mEq daily and to check BMP in 1 week. The 11/1/22 at 2:24 PM, LPN #7 documented the NP reviewed the UA and ordered Macrobid. The 11/1/22 physician order documented Macrobid (antibiotic) 100 mg twice a day for 7 days due to abnormal urinalysis and leukocytosis. KCl 30 mEq once a day for 2 days then 10 mEq daily. The 11/3/22 NP #27 progress note documented the resident's labs from last week were available on 11/1/22. The resident's potassium was 3.1 noted, however a few days had passed by, and I did not replace it because I did not know if K (potassium) was normal. The resident's UA came back positive for bacteria and a white blood cell count; the resident was empirically started on Macrobid pending the urine culture. The 11/5/22 attending physician's Discharge Summary documented the resident had just been started on Macrobid for a UTI. Later, the resident's oxygen saturations dropped to 82% and they transferred the resident to the emergency room . They were admitted with pneumonia and UTI. 2) Resident #5 was admitted to the facility with diagnoses including urinary retention. The 3/4/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required supervision and/or limited assistance for activities of daily living (ADL). The 3/8/22 Laboratory Report documented the labs resulted at 8:41 AM and the resident's sodium (electrolyte which can relate to hydration) was 132 mEq/L (milliequivalent per liter, normal 134 to 153, low), potassium (electrolyte) was 4.2 mEq/L (normal 3.6 to 5.0, normal), chloride (can measure hydration) was 90 mEq/L (normal 97 to 107, low), carbon dioxide was 32 mEq/L (normal 22-30, high), blood urea nitrogen (BUN, measures hydration and kidney function) was 47 mg/dl (milligrams per deciliter, normal 7-21, high), and Creatinine (measures hydration and kidney function) was 2.3 mg/dl (normal 0.7-1.5). Licensed practical nurse (LPN) #17 documented the labs were noted on 3/11/23. The attending physician wrote a note dated 3/11/22 which documented to discontinue spironolactone (diuretic), add potassium chloride (potassium supplement) 10 mEq daily, and BMP (basic metabolic panel, blood test) in 2 weeks. The 3/11/22 LPN #17's progress note documented labs were reviewed by the physician with a new order to discontinue Aldactone (spironolactone, diuretic), start K-Dur (potassium chloride supplement) 10 mEq daily, and recheck BMP in 2 weeks. The 3/11/22 physician order documented KCl, 10 mEq once a day. Spironolactone was discontinued. 3) Resident #6 was admitted to the facility with diagnoses including visual loss, dementia, and systemic lupus erythematous. The 2/12/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognitive skills, and required extensive assistance or total dependence for activities of daily living (ADL). The 3/8/22 Laboratory Report documented the lab resulted at 8:37 AM, and the resident's blood urea nitrogen (BUN, measures hydration and kidney function) was 22 mg/dl (milligrams per deciliter, normal range 7 to 21, high), and Creatinine (measures hydration and kidney function) was 0.5 mg/dl (normal range 0.7 to 1.5, low). The resident's BUN/Cr of 44 was circled (normal range 8 to 27). LPN #17 signed they reviewed the labs on 3/11/22 and they would encourage the resident to eat and drink by mouth. During an interview on 3/31/23 at 3:47 PM, LPN #7 stated when labs resulted, they would be faxed to 2 facility fax machines and the LPN would call the physician with the results. The LPN was unsure why Resident #2's labs were not reviewed from 10/27/22 to 10/31/22. Labs usually resulted on the same day. The LPN stated if the floor nurse did not see the results, the Unit Manager or the Supervisor would assist. The lab would sometimes send results one day, and then a duplicate later in the week or the fax machine would be down. The floor LPNs would also be expected to follow up if results for labs were still pending. The LPN stated it was the Unit Manager's overall responsibility to follow-up on lab results and they would ask the floor LPN to follow up if they were unable to. During an interview on 4/4/23 at 10:15 AM, LPN #2 stated lab results were faxed from the lab to the nurse Supervisor's office and the Unit Manager would go through the results. The Unit Manager would put the labs in the physician communication book, and they would review and write orders as needed. The LPN did not do much with laboratory results as a medication nurse unless asked or if they were working alone on the evening shift when the labs resulted. They were unsure why Resident #5 and 6's labs were not reviewed from 3/8/22 to 3/11/22. During an interview on 4/5/23 at 9:07 AM, LPN #17 stated that when they worked as a LPN Unit Manager or Supervisor, it was their responsibility to check lab results. Labs were usually drawn on two days of the week and the results would come in. LPN #7 stated that management had stated it was everyone's responsibility to check for laboratory results. The LPN's process was to check the printer for labs, review for any abnormal results and then to contact the provider. There were times they would notify the physician, who would state they had already been notified and had made recommendations, which was not documented in the electronic medical record. The lab also sent duplicate results to the printer in the nursing office as well as the front office. The LPN stated that if they reviewed the lab results on 3/11/22 after they had resulted on 3/8/22, they were likely the one to pull them off the fax machine. If the physician had made changes or written orders, it was a delay in care from 3/8/22 to 3/11/22 for Residents #5 and #6. During an interview on 4/13/23 at 11:31 AM, LPN #16 stated the physician was to be notified right away if a resident's laboratory results had anything abnormal. The results were faxed to the printer in the nursing office, then placed in a bin for the Supervisor or Unit Manager to pick them up. The process for following up with pending labs had not been consistent, so the facility was utilizing a lab book to document when labs were ordered and if they had resulted. For Resident #5, the resident's labs should have been reviewed on the day they had resulted and should not have gone 3 days before they were reported. With Resident #6, the LPN stated that the resident's labs should have been reviewed with their previous results and documented that the laboratory results were reviewed. Ultimately, labs should be reviewed on the day they were resulted to check for anything abnormal and it was best practice to document that the results were reviewed. When asked about Resident #2 and having the labs redrawn or the resident with a high WBC and possible UTI without intervention, the LPN stated it would be best practice to report the labs on that day. A high WBC was indicative of an infection, and if the resident had a high WBC and UTI, there was potential for the infection to get worse if it was untreated. During an interview on 4/14/23 at 10:55 AM, NP #27 stated the facility did not have labs which automatically uploaded into the electronic medical record and the NP could not directly access the laboratory portal to review lab results so the NP relied on the facility nurses to receive and review the labs first, then notify them of any abnormal results. The NP expected to be notified the same day of any abnormal results. The NP stated potassium could vary and the NP did not feel comfortable replacing potassium based on a level from 4 days prior, so they requested the labs be redrawn. Had they been notified that day or the day after, the NP would have provided potassium supplementation at that time and checked again the next week. The fax machine was in an office which was sometimes locked and not everyone had access to the lab portal to review them electronically. The NP worked at different facilities which allowed them to have direct access to the laboratory results which allowed for better follow up. During an interview on 4/14/23 at 1:23 PM, the attending physician stated they expected the nursing staff to call as soon as abnormal lab results came in. The physician had been at the facility that day and had labs they were reviewing from 4/6/23. The physician stated they could not recall the residents. 10NYCRR 415.21(b)(1)

Based on interview and record review during an abbreviated survey (NY00292846), the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 3 residents (Resident #6) reviewed. Specifically, Resident #6 had bruising of unknown origin that was not thoroughly investigated to rule out abuse, neglect, or mistreatment and when direct care staff identified the injuries of unknown origin, there was no documented evidence they reported them to Administration immediately. Findings include: The facility policy Accidents - Incidents revised 7/2020 documented an incident was any occurrence which could include a skin tear or bruise. The Incident Form should include the type of injury and diagram of the location of the injury, any corrective actions or interventions immediately put into place to prevent further incidents, follow up information, and signature and title of the person completing the report. The Director of Nursing (DON) and Administrator were responsible to review the Incident/Investigation and conclusion to determine if the incident required reporting to outside agencies. Resident #6 was admitted to the facility with diagnoses including visual loss and dementia. The 9/22/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance for bed mobility, transferring, walking in their room, toileting, and personal hygiene. The 5/20/21 comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADL). Staff were to inspect the resident's skin for redness, open areas, scratches, cuts, or bruises, and were to report any changes to the nurse. The resident exhibited behavioral symptoms including verbal and physical aggression towards others, fidgeting, throwing items around the room, pulling out drawers, agitation, restlessness, and aggressive behaviors. Updates to the CCP included on 7/1/21, leave the resident alone during a period of agitation and reapproach at a different time; on 9/7/21, allow the resident to call their family during periods of agitation, and on 10/1/21, remove the resident from unsafe situations and redirect. The Grievance Form documented occupational therapist (OT) #31 observed the resident with reddened areas to the periorbital eye and ear during a session on 10/1/21 and reported this to former Director of Nursing (DON) #23. Former DON #23 documented they assessed and interviewed the resident, interviewed staff, and a physician and psych evaluation was ordered. The form documented there was no evidence of abuse or neglect found upon investigation. The 10/1/21 at 11:43 AM, former DON #23's progress note documented the resident had new skin alterations including left ear redness and right antecubital (inner elbow) ecchymosis (discoloration of the skin usually caused by bruising). Last blood draw on 9/28/21 and left periorbital eye redness. The resident denied pain or discomfort. The 10/1/21 Incident Report documented the resident had a bruise on their left ear and a puffy left eye, which was discovered at 11:20 AM. The report was initiated by licensed practical nurse (LPN) Supervisor #16. Statements included with the Incident Report documented: - LPN Supervisor #16 documented they were were notified by former DON #23 the resident had a new skin impairment. The resident's left eye was puffy with pink under the eye. The left side was also pink, and their left ear was pink to red in color. Prior to the incident, the resident was sleeping. The resident stated someone beat me up. - LPN #30 documented they were notified by the certified nurse aides (CNA) that the resident's left eye was bruised when they were getting the resident out of bed. LPN #30 observed the resident's left eye to be bruised. The resident was lying in bed sleeping prior to the incident and the resident stated they did not know what happened. - Temporary nurse aide (TNA) #33 documented they and CNA #32 saw the resident's eye when they were getting the resident up on 10/1/21. CNA #32 and TNA #33 got the resident washed, dressed, in their chair, and toileted; then CNA #32 walked the resident down for their appointment. A second statement by TNA #33 documented they were approached by former DON #23 for their statement. - CNA #34 documented at the beginning of the shift (shift not identified), the resident was sitting at the nurse's station. At 9:00 PM, they assisted the resident to bed. At 10:00 PM, CNA #34 helped the resident back to bed after they walked in the hallway. CNA #34 ended their shift with nothing observed on the resident's face. The date CNA #34 worked with the resident was not documented. - OT #31 documented at the beginning of a treatment session on 10/1/21 at 11:00 AM, the resident was observed with redness on the left eye and ear which was not present the day before. - CNA #35 documented on 10/1/21 at 1:25 AM, they observed the resident to have 2 large bruises. One bruise was on the inner arm (side not documented) and the other was on the left tricep (outer upper arm). There was no documentation whether the facility determined a cause of the bruising or if the facility determined whether the CCP was followed when the injuries occurred. There was no documentation if the arm bruising identified by CNA #35 was investigated. During an interview on 4/13/23 at 11:31 AM, LPN Supervisor #16 stated if a new bruise or skin tear was reported, they would look a the resident and initiate an investigation to determine how they got the bruise. A registered nurse (RN) would update the CCP and close out the Incident Report. LPNs reviewed statements and put them with the Incident Reports. If they saw a statement that documented arm bruising when reviewing an Incident Report for eye bruising, they would ask more questions. The vaguely recalled the resident; they did not know what interventions the resident had in place. The resident was blind and very mobile; they could get around but would forget that they were unable to see. The resident was dangerous to themselves due to their mobility and impaired vision. During an interview on 4/14/23 at 2:08 PM, current DON #1 stated they would complete an Incident Report if a resident had an injury of unknown origin. An investigation was completed to make sure no abuse happened. If a resident had an injury, an investigation was completed to determine what happened, and interventions would be put in place to prevent recurrence. DON #1 reviewed the 10/1/21 Incident Report and stated CNA #35's statement did not seem to be related to the incident being investigated. DON #1 stated the investigation was inconclusive and there was no determination of what could have occurred or interventions put into place. The DON stated the CNAs who got the resident up and transported them to therapy should have reported the skin impairment to the nurse or Supervisor immediately, rather than taking the resident to therapy. The statements were inconsistent; some documented the area was pink or puffing, others documented there was bruising or a darkened color. Usually the Incident Report documented what the active CCP was at the time of the incident, and none was available. The DON stated that the bruising on the arm should have had a separate investigation. The DON would also complete an assessment themselves to determine what skin alterations the resident had. They stated they did not think the 10/1/21 Incident Report was thorough. 10NYCRR 415.4(b)(3)

Based on record review and interview during the abbreviated survey (NY 107), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 3 of 3 residents reviewed (Residents #2, 6, and 11). Specifically: - Resident #2 had no ordered treatment to a left finger wound for 3 days, no ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . - Resident #6 was admitted to the facility with a venous ulcer (wound resulting from poor blood flow) on the right lower leg. The wound was not thoroughly assessed by a qualified professional for 14 days after admission and treatment to the wound was not completed for 8 days. - Resident #11's had wounds to their left heel, wound treatment recommendations were not implemented for 3 or more days, and when the wounds worsened, new treatment recommendations were not implemented for greater than 3 days, treatments were not consistently administered as ordered, and recommended interventions were not added to the comprehensive care plan (CCP). This resulted in actual harm to Resident #11 as their wounds worsened and they developed an infection when treatment recommendations were not ordered and implemented and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #2 and 6. Findings include: The facility policy Protocol: Wound Care and Rounding updated 12/2021, documented all new admissions would have a complete body check on admission to identify any open areas. On admission the registered nurse (RN) or designee should document on admission skin assessment; size, depth, stage, and appearance of open areas in the resident's electronic health record. The physician should be notified to obtain appropriate treatment orders and the licensed nurse should initiate a care plan as necessary. The resident should be added to the facility wound tracking list and should be seen for weekly wound rounds. Wounds were to be measured and assessed weekly and documented in the resident's medical record. Any wound identified as worsening would be reviewed by the physician and treatment changes made as indicated. The resident's care plan would be updated to reflect the deterioration. 1) Resident #11 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/21/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required supervision with bed mobility and extensive assistance of 1 with transfers, was at risk for pressure ulcers, had 3 venous/arterial ulcers, had an infection of the foot, and diabetic ulcers (wounds). The comprehensive care plan (CCP) initiated 6/17/21 documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CCP was resolved on 6/29/21. The 11/1/21 CCP documented the resident had limited physical mobility, impaired skin integrity and was at risk for pressure ulcers. Interventions included non-ambulatory status, a heel off loader on the left foot while in the wheelchair, weekly wound assessments, refer to appropriate medical specialist as needed, remind resident of importance of leaving dressing in place, extensive assistance of 1 with transfers and bed mobility, skin observations, and an air mattress. The 2/8/22 Assistant Director of Nursing (ADON) #1's weekly wound note documented the resident had a left lateral heel (outer side) abrasion (scrape) identified that day that measured 0.2 centimeters (cm) x 0.2 cm x 0 cm. [MEDICATION(S)] (dressing) was to be applied every 3 days. There was no documentation the [MEDICATION(S)] was ordered, or a treatment was completed to the left lateral heel abrasion from 2/8/22 through 2/15/22 (8 days). There was no documentation the CCP was updated to include impaired skin integrity of the left lateral heel. The 2/15/22 facility wound physician #12's progress note documented: - a new diabetic wound on the left lateral heel that measured 1.2 cm x 1.4 cm x 0 cm that was a fluid filled blister. A foam dressing was to be applied every 3 days. - A new diabetic wound on the left posterior (back) heel that measured 0.6 cm x 0.5 cm x 0 cm that was a dried scab. [MEDICATION(S)] (anti-septic) was to be applied daily. The 2/16/22 physician's order documented [MEDICATION(S)] to the left posterior heel was ordered. There was no documentation of a treatment order to the left lateral heel (foam dressing). There was no documentation of who had entered the orders into the EMR. The 2/15/22 physician's order documented to apply foam dressing daily to left lateral heel wound with a start date of 2/18/22 (3 days after the recommendation by facility wound physician #12). There was no documentation of who had entered the orders into the EMR. The 2/23/22 ADON #1's weekly wound note did not document an assessment of the resident's left foot wounds. The 3/1/22 facility wound physician #12's progress note documented: - the left lateral heel wound measured 2.2 cm x 2.6 cm x 0 cm, had odor, 100% thick necrotic (dead) tissue, moderate serous (watery) drainage and had deteriorated. The treatment was to be changed to Leptospermum honey daily (used to facilitate wound healing), ABD (abdominal pad, dry dressing), and wrapped with Kerlix (dressing). - the left posterior heel wound measured 1 cm x 1.2 cm x 0.1 cm, had moderate serous drainage and 100% slough (yellow, dead tissue). The treatment was to be changed to Leptospermum honey daily, ABD, and wrapped with Kerlix. The 3/1/22 physician's orders documented: - To the left lateral heel, [MEDICATION(S)] (Leptospermum honey), cover with ABD, and wrap with Kerlix daily. - To the left posterior heel, [MEDICATION(S)], cover with ABD, and wrap with Kerlix daily. The order to the left posterior heel was discontinued on 3/2/22 and a new order was not implemented. There was no documentation why the treatment was discontinued or documentation of who had entered the orders into the EMR on 3/2/22. The 3/8/22 wound culture report documented the resident's left heel had bacteria including Proteus, staphylococcus, and Enterobactor. The 3/8/22 facility wound physician #12's note documented: - the left lateral heel wound measured 2.7 cm x 2.7 cm x 0 cm, had 100% black necrotic tissue and was a fluid filled blister. The treatment was to be changed to [MEDICATION(S)] (antibiotic cream) with gauze island dressing daily. - The left posterior heel wound measured 0.4 cm x 0.4 cm x 0 cm and was a dried scab. Apply [MEDICATION(S)] daily. The 3/2022 Treatment Administration Record (TAR) documented: - [MEDICATION(S)] continued to the left lateral heel through 3/15/22. [MEDICATION(S)] was not ordered on 3/8/2022 as recommended by facility wound physician #12. - There was no documented evidence of a treatment to the left posterior heel from 3/2/22 through 3/15/22. The 3/15/22 facility wound physician #12's progress note documented: - the left lateral heel wound was 2.2 cm x 2.5 cm x 0 cm, had 100% black necrotic and was a fluid filled blister. The treatment was to be changed to Santyl ([MEDICATION(S)] agent, removes dead tissue), ABD, and Kerlix daily. - The left posterior heel wound was 0.3 cm x 0.3 cm x 0 cm and was a dried scab. Continue [MEDICATION(S)] daily. The 3/2022 TAR documented: - Santyl to left lateral heel was ordered on 3/16/22. There was no documentation the treatment was completed on 3/25/22 and 3/26/22. - [MEDICATION(S)] to left posterior heel was ordered on 3/16/22 and administered from 3/16/22 to 3/31/22. There was no documentation the treatment was completed on 3/21/22, 3/25/22 and 3/26/22. The 3/16/22, updated CCP, documented the resident had impaired skin integrity related to arterial/ischemic ulcer, and ulceration of left foot wounds. Interventions included treatments, weekly wound assessments, notify physician as needed, monitor, document, and report signs of infection, and refer to medical specialist as needed. The 3/29/22 facility wound #12's physician's progress note documented: - the left lateral heel wound measured 2.6 cm x 2.3 cm x 0 cm, had moderate serous drainage, 100% thick necrotic tissue, and was improved. Continue Santyl, add calcium alginate (absorbent dressing) and cover with ABD and Kerlix daily. - the left posterior heel wound was resolved. The 3/2022 and 4/2022 TAR documented Santyl was administered to the left lateral heel from 3/29/22 to 4/7/22. There was no documentation the treatment order was changed to include the addition of calcium alginate. The 4/5/22 facility wound physician #12's progress note documented the left lateral heel wound was 2.8 cm x 2.5 cm x 0.5 cm, had moderate serous drainage, 100% thick necrotic tissue and was deteriorated. The recommendation was to continue Santyl, calcium alginate, ABD and Kerlix daily. There was no documentation the resident was receiving the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/2022 TAR documented on 4/8/22, the order to the left lateral heel was changed to Santyl, calcium alginate, ABD and wrapped with Kerlix and was administered daily to left lateral heel through 4/19/22. The order was implemented 10 days after the recommendation by wound physician #12. The 4/19/22 ADON #1's weekly wound assessment documented the resident's left heel was 3 cm x 3.5 cm x 0.5 cm, had 20% slough, 80% eschar (non-viable tissue) and was improved. The 4/20/22 physician's order documented [MEDICATION(S)] Blue (anti-bacterial treatment) to the left lateral heel every 3 days. The 4/27/22 facility wound physician #12's progress note documented: - the left lateral heel wound measured 4 cm x 3.5 cm x 0.5 cm with a surrounding deep tissue injury (DTI, purple/maroon area of intact skin). There was moderate serous drainage, 100% thick necrotic tissue, and the wound had deteriorated. Change to calcium alginate, Santyl, Dakin's (antiseptic wash) wash, ABD, Kerlix daily. [MEDICATION(S)] (antibiotic) 500 milligrams (mg) x 7 days per primary team for wound infection. There was no documentation the treatment order was changed as recommended on 4/27/22 by facility wound physician #12. The 4/2022 TAR documented [MEDICATION(S)] Blue continued every 3 days through 5/11/22. The 5/11/22 outside wound physician #17's progress note documented the resident's left heel wound measured 3.5 cm x 4.6 cm x 0.5 cm, had moderate serosanguinous (blood tinged) drainage, odor, and large necrosis 67-100%. Recommendations included calcium alginate and adhesive foam every other day. The 5/11/22 physician order documented calcium alginate to left heel every 2 days and cover with [MEDICATION(S)]. The 5/18/22 outside wound physician #17's progress note documented the resident's left heel wound measured 3.5 cm x 4.6 cm x 0.5 cm, had moderate serosanguinous drainage, odor, and large necrosis 67-100%. The consult documented to order a Wound V.A.C. (vacuum assisted closure, negative pressure wound therapy) for the resident's left heel with black foam at 100 millimeters of mercury (mmHg) and change Monday, Wednesday, and Friday. Calcium alginate and foam dressing were applied in the office. The 5/18/22 physician order documented calcium alginate to left heel every 2 days. Discontinue when Wound V.A.C. arrived. On 5/20/22, the resident was discharged to the hospital for issues not related to their left heel wound. On 6/27/22 at 12:36 PM, ADON #1 stated in a telephone interview, all treatment recommendations made by consultants were reviewed by the nurse on the floor when the resident returned from their appointment and reviewed with the facility physician for approval. Orders should be implemented within 24 hours. They stated they could not recall a time when the facility physician did not agree with the resident's outside wound consultant recommendations. On 7/6/22 at 9:34 AM, licensed practical nurse (LPN) #16 stated in a telephone interview, after residents returned from outside consults, the nurse reviewed recommendations and contacted the facility physician to obtain orders. When orders were obtained, the order was put into the electronic record and sent directly to the pharmacy via the electronic record. On 7/14/22 at 10:22 AM, LPN #8 stated in a telephone interview consult recommendations were typically handled by the Nurse Manager or Supervisor and if not, by the floor LPN. The floor LPN might not have enough time to review the consults due to having other tasks to complete. On 7/14/22 at 10:37 AM, ADON #1 was re-interviewed and stated: - They were not aware the resident had no treatment to their heel abrasion after they assessed the resident on 2/8/22. They were alerted by a nurse to assess the area on 2/8/22 and that nurse (did not recall who) was supposed to call for a treatment order. They stated they expected an order to be in place. - The facility wound physician could not enter their own orders. Once their consult was completed, the floor nurse accessed it from the computer and was responsible to review recommendations with the physician. The Nurse Manager was ultimately responsible to ensure orders were implemented. - On 2/15/22, the nurse should have looked at the consult and obtained orders. - They tracked wounds weekly to ensure a treatment was in place and to be sure wounds did not deteriorate. If wounds were not tracked, the wound could deteriorate. They used a wound tracker to ensure all resident wounds were tracked weekly. - On 2/23/22, they could not recall why they did not assess the resident's left heel and could have forgotten to document. - They were not aware there was no treatment in place to the resident's left posterior heel and there should have been a treatment order in place. - Typically, the facility physician agreed with recommendations made by the facility wound care physician and wound physician #17 and if the physician did not agree with recommendations, a note should be written by the nurse documenting the rationale. - On 3/8/22, they were not sure why the treatment order was not changed, and it should have been if the physician agreed to it. They stated they did not see an order on 3/8/22 to the left lateral heel or the left posterior heel. - On 3/29/22, they were not aware that calcium alginate was not added. When it was added on 4/8/22, it was not done timely. - On 4/20/22, they were not sure why [MEDICATION(S)] Blue was ordered and was not something they recommended. They stated a note should have been written by the nurse obtaining the order. - On 4/27/22, they were not aware that [MEDICATION(S)] Blue continued for 2 more weeks after the facility wound physician recommended it be changed to a different treatment. On 7/20/22 at 11:31 AM, facility wound physician #12 stated in a telephone interview: - a nurse usually rounded with them, and they communicated their recommendations with the nurse. They also documented their recommendations in their wound note which was available a few hours after the resident was evaluated. - They were not able to input their own orders. The nursing staff communicated their recommendations with the facility physician and the facility physician was always agreeable to their recommendations. Once the facility physician accepted their recommendations, they expected orders to be implemented within 24 hours. If a treatment was delayed because of pharmacy issues, there should be an alternative plan. - On 2/16/22, they expected treatment orders for the resident's heel wounds and was not aware there were no orders for the left lateral heel. - [MEDICATION(S)] was a treatment that facilitated debridement and they were not sure why [MEDICATION(S)] was discontinued on 3/2/22. - [MEDICATION(S)] was a topical antimicrobial specific for [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)], bacteria that is difficult to treat) infections in wounds and was why they recommended it based on the 3/8/22 wound culture. They were not aware the treatment was not started, and the resident had no treatment to the left posterior heel. Calcium alginate was a dressing that helped with absorption of wound drainage. Santyl that was ordered at the same time which typically caused wounds to get wet around the edges and they ordered calcium alginate to help absorb drainage. They were not aware calcium alginate was not ordered on 3/29/22. - They were not sure why [MEDICATION(S)] Blue was ordered on 4/20/22 and thought outside wound physician #17 ordered it. On 7/20/22 at 12:50 PM, Case Manager #36 at outside wound physician #17's office stated in a telephone interview, they first evaluated the resident at their office on 5/11/22 and outside wound physician #17 did not make recommendations for treatments including [MEDICATION(S)] Blue to the resident's wounds prior to that date. On 7/21/22 at 9 AM, physician #22 stated in a telephone interview: - facility wound physician #12 either called them directly with recommendations or staff communicated the recommendations to them. Orders should be obtained and implemented immediately or no later than 12 hours. They usually agreed with facility wound physician #12's and outside wound physician #17's recommendations because they were the wound experts. The wound physician would usually call them and discuss the orders, the wound physician would then call a nurse with their orders and physician #22 would approve the orders. - The timing of reassessing wounds depended on the facility wound physician #12's schedule. Facility wound physician #12 was typically at the facility 2 days weekly and they were responsible to determine how often the residents' wounds were to be reassessed. - They recalled Resident #11, was not aware orders were not obtained for [MEDICATION(S)] on 2/8/22, and there should have been a treatment order in place. - On 2/15/22, after facility wound physician #12 assessed the resident and made recommendations to the left lateral heel wound, they were not aware orders were not obtained and should have been. - On 3/2/22, they were not sure why orders were discontinued to the left posterior heel wound and an alternate order should have been obtained. - On 3/8/22, the staff should have called them to obtain orders for [MEDICATION(S)] and was not aware it was not ordered. - They were not aware that calcium alginate was not ordered on 3/29/22 and should have been. - They were not sure why [MEDICATION(S)] Blue was ordered on 4/19/22. - On 4/27/22, orders should have been obtained to add Dakin's and they were not sure why they were not. 2) Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/17/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 2 for bed mobility, transfers, dressing, toileting, and personal hygiene, had one Stage II (partial thickness loss of skin layer) pressure ulcer, and 4 venous and arterial ulcers (wounds related to poor blood flow). The 3/11/21 at 9:11 PM, former Director of Nursing (DON) #18's progress note documented the resident had venous stasis ulcers on both legs. The 3/11/21 Admission Assessment by former DON #18 documented the resident had a vascular wound on the front of their right lower leg measuring 2.5 centimeters (cm) in length and 3 cm in width. The assessment did not document wound characteristics such as appearance, presence of exudate (drainage), and current treatment. The 3/11/21 comprehensive care plan (CCP), initiated 3/11/21 documented the resident had impaired skin integrity related to venous stasis ulcers. Interventions included applying treatment per medical order, documenting the location of the wound, amount of drainage, peri-wound area (surrounding skin), pain, [CONDITION(S)] (swelling) and circumference measurements; evaluating the wound for size, depth, margins (edges), sinuses (open tracts under the skin extending from the wound), undermining (pocket under the wound edges), exudates (fluid), granulation (new tissue), infection, necrosis, eschar, gangrene (dead tissue); documenting progress of wound healing on an ongoing basis; and referring to appropriate medical specialist as needed for evaluation and treatment. The CCP documented that the resident saw outside wound physician #17. Physician orders documented: - On 3/11/21, follow-up with outside wound physician #17 in 1 week. - On 3/11/21, weekly skin evaluation done on Friday evenings. - On 3/11/21, venous ulcer right lower leg, cleanse with normal saline (NS) and apply [MEDICATION(S)] (dressing), wrap with [MEDICATION(S)] (elastic tubular bandage), change every 2 days, and as needed (prn). This order was discontinued on 3/13/21 at 2:30 PM. - On 3/13/21, venous ulcer right lower leg, cleanse with NS and apply [MEDICATION(S)], wrap with [MEDICATION(S)], change every 2 days, and as needed. This order was discontinued on 3/14/21 at 4:11 PM. - On 3/14/21 to start 3/15/21, venous ulcer right lower leg, cleanse with NS and apply [MEDICATION(S)], wrap with [MEDICATION(S)], change every 2 days, and as needed. This order was discontinued on 3/15/21 at 10:46 PM. - On 3/21/21 with an end date of 3/25/22 venous stasis ulcer of right calf, cleanse with NS, apply [MEDICATION(S)] to wound base daily and prn (as needed), cover with gauze and Kling dressing every day shift. There was no documentation of who had entered the orders into the EMR. The 3/2021 Treatment Administration Record (TAR) documented a treatment was completed to the right lower leg venous ulcer on 3/12/21 and 3/13/21. There was no treatment order for the right lower leg venous ulcer from 3/16/22 through 3/21/22. There was no documented treatment administered to the right lower leg venous ulcer from 3/14/22 through 3/21/21. There was no nursing documentation referencing treatments to the right lower leg venous ulcer from 3/14/22 through 3/21/22. The 3/18/21 at 5:25 PM skin monitoring progress note by licensed practical nurse (LPN) #27 documented weekly skin monitoring was completed and no new skin alterations were noted. There were no new skin issues and treatments continued to bilateral legs. The progress note did not document the characteristics of the venous ulcer on the right lower leg. The 3/25/21 at 11:48 AM former DON #20 documented the initial wound documentation for the right rear lower leg vascular wound. The wound measured 7 cm x 3.8 cm x 0.3 cm and was identified on 3/25/21. The wound had 100% granulation tissue with a moderate amount of serous exudate and no odor or pain. Biofilm (slimy layer of bacteria) was removed from the wound. The plan was to cleanse with normal saline, blot dry, apply calcium alginate with silver (antibacterial), cover with gauze and secure with Kerlix dressing. Interventions in place were a specialty mattress and removal of biofilm to promote healing. The 3/25/21 initial wound evaluation by facility wound physician #12 documented a venous wound of the right lateral leg measuring 7 cm x 3.8 cm x 0.3 cm, with a moderate amount of serous exudate and 100% granulation tissue. The wound was in an [CONDITION(S)] stage (phase of wound healing with inflammation or redness, [CONDITION(S)], heat, and pain) and was unable to progress to a healing phase because of the presence of a biofilm. The wound was debrided (removal of dead tissue). The treatment plan was to discontinue [MEDICATION(S)], foam silicone border and faced dressing, and apply Skin Prep (liquid skin protectant) to the skin around the wound, then apply calcium alginate with silver to the wound bed, cover with sterile gauze sponges and wrap with Kerlix daily. The recommendation was to cleanse with Dakin's, off-load wound, and reposition per facility protocol. On 6/22/22 at 2:50 PM in a telephone interview, former DON #18 stated when a resident was admitted , all wounds were documented with size and location noted. They would obtain orders for the wound treatment, either from the hospital discharge paperwork or from the physician. There was a wound specialist who came to the facility. The nurses would fax the face sheet of the resident who needed to be seen to the wound specialist's office and they usually saw the resident within 1 week. Former DON #18 did not know why Resident #6 had not been assessed by a qualified professional until 3/25/21 and did not know why there were no orders for wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . They stated that if a wound was not treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/28/22 at 11:50 AM in an interview, LPN #7 Unit Manager stated they were not at the facility when Resident #6 was at the facility. They were able to access the medical record for Resident #6 and saw an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They expected if an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . They said that it did not make sense that there were no treatment orders from 3/16/21-3/21/22. They stated that an RN should be assessing any wounds weekly and if treatments were not done it could lead to infection or deterioration of the wound. On 6/30/22 at 9:36 AM, LPN #3 stated in an interview they only discontinued a wound order if the wound had healed, or the treatment needed to be changed. They stated that if a wound had changed or healed, then that should be noted in the medical record. They could not recall why the right lower leg wound treatment on 3/15/22 was not marked as done or why the order for wound treatment was discontinued to the right lower leg and another order was not placed. They stated that the wound may have healed and re-opened between 3/15/22 and 3/21/22 and they had forgotten to put in a note. They said that a RN should have assessed the wound weekly if the wound physician did not see the resident within one week. They stated it was important that wounds be assessed regularly to make sure that they were healing and not declining. During a telephone interview on 7/21/22 at 9 AM, attending physician #22 stated for wound assessments, it depended on the resident's wounds and how often the wound physician wanted to assess. They recalled the resident and stated they were not aware they did not have a treatment order in place, they would never discontinue the order and there should have been an order in place. If the resident's wounds were not assessed for 2 weeks after admission it was not done timely. 3) Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/10/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of 2 with bed mobility and transfers, had a surgical wound, and an infection of the foot. The 3/4/22 Admission Assessment completed by LPN #41 documented the resident was at the facility for rehabilitation, the resident had left foot gangrene and both legs had scattered scabbed areas and thick scaled skin. The 3/4/22 ADON #1's wound assessment documented: - left plantar (bottom) foot diabetic wound was 5.3 centimeters (cm) x 4.2 cm x 0.5 cm and had 30% fascia/tendon/muscle. - left second finger gout (uric acid buildup) wound was 1.5 cm x 1.2 cm x 0.2 cm, had 100% epithelial tissue (new skin growing in superficial ulcer) and moderate serous (watery) drainage. The 3/4/22 physician's orders documented left foot soaked in wound cleanser for 15 minutes then [MEDICATION(S)] Blue (antibacterial) covered with Optilock (dressing), Kerlix and Ace wrap every 2 days on the evening shift. There was no documented evidence of a treatment ordered to the resident's left finger wound. The 3/7/22 comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADL), they were at risk of pressure ulcers, and they had a wound infection. Interventions included the resident required extensive assistance of 1 with bed mobility and extensive assistance of 2 with transfers, monitor skin for open areas and report to nurse, inflatable Prafo boot (pressure relief) on the right foot and provide medications and treatments as ordered. The 3/8/22 admission history and physical documented the resident was admitted to the hospital with a wound infection, gas gangrene and [CONDITION(S)] (bone infection). They underwent incision and drainage (I&D) to the left foot with excision of 1st metatarsal head (great toe). They needed further left foot I&D and surgical debridement with wound dressing application. Wound cultures grew [CONDITION(S)], and they were started on antibiotics. The resident was transferred to rehabilitation for wound care, needed follow up surgery, and follow up with a wound specialist. The 3/8/22 facility's wound physician #12's initial evaluation note documented: - The left plantar foot diabetic wound was 5.3 cm x 4.2 cm x 0.5 cm with 30% eschar, 20% necrotic (dead) tissue, 20% slough (yellow dead tissue) and 30% visible fascia, tendon, muscle. Recommended treatment plan was [MEDICATION(S)] Blue, ABD and Kerlix daily. - The left 2nd finger Gout with tophi (deposits under skin) had ulcerated the overlying skin and was 1.5 cm x 1.2 cm x 0.2 cm with moderate serous drainage. Apply foam silicone dressing every 3 days. The resident was under the care of an outside wound physician and a surgeon (podiatrist), and it was anticipated they would resume care with them. Follow-up with surgeon. The 3/2022 Treatment Administration Record (TAR) did not document a treatment to the residents left 2nd finger from 3/4 through 3/8/22. The treatment was completed as ordered to the left plantar foot wound. The 3/15/22 facility's wound physician's #12's progress note documented: - The left 2nd finger was 0.9 cm x 1.3 cm x 0.2 cm, had 50% necrotic tissue, 50% dermis (skin layer) and was improved. Soft uric acid crystals were removed. The plan was [MEDICATION(S)] (non-adherent dressing) and Coban wrap (dressing). - The left plantar foot was 5.3 cm x 4.2 cm x 0.5 cm, had 10% necrotic tissue, 60% slough, 30% fascia/tendon/muscle and was improved. The resident's wound was managed by their surgeon. The plan was [MEDICATION(S)] Blue, ABD, Kerlix, and ACE bandage. The 3/18/22 outside wound physician #17's note documented: - to the left second finger, a foam dressing 3 times weekly. - to the left foot, Drawtex (treatment), [MEDICATION(S)] blue, Kerlix, and Xtrasorb (absorbent dressing) 3 times weekly. The 3/18/22 at 5:14 PM LPN #16 note documented the resident went to the wound specialist for their left foot and left 2nd digit, the physician was aware and new orders received. The 3/18/22 physician orders did not document a new treatment order was obtained for the resident's left foot as recommended by wound physician #17. The 3/22 TAR documented: - on 3/18/22, to left foot, [MEDICATION(S)] Blue, ABD and Kerlix was documented by LPN #16 as 9 other/see nurse note. There was no further treatment documented on the TAR from 3/19 through 3/21/22. The 3/22/22 physician order (4 days after wound physician #17 recommendation) documented to left foot, apply Drawtex, [MEDICATION(S)] Blue, [MEDICATION(S)] (dressing) and wrap with Kerlix 3 times weekly. The 3/29/22 facility's wound physician #12's progress note docum

Based on record review and interview during the abbreviated survey (NY 107), the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individuals condition demonstrated that they were unavoidable; and 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 2 of 3 residents (Residents #4 and 5) reviewed. Specifically: - Resident #4 was admitted to the facility with unstageable (full thickness tissue loss where the base of the ulcer is covered with dead tissue) pressure ulcers and treatment orders were not obtained timely or completed consistently. Additionally, the resident was evaluated by an outside wound physician and recommended treatments were not ordered or implemented for 3 or more days. When the treatment was not available, an alternate treatment order was not obtained. - Resident #5 was admitted with a bruised area on their buttocks, the area was not monitored or treated, and the area progressed into a Stage 3 (full thickness tissue loss) pressure ulcer. This resulted in actual harm to Resident #5 when a bruise progressed into a Stage 3 pressure ulcer when a care plan and treatments were not implemented to prevent pressure ulcers. Findings include: The facility policy Protocol: Wound Care and Rounding updated 12/2021, documented all new admissions would have a completed body check that identified any open areas. The physician should be notified to obtain appropriate treatment and the licensed nurse initiate a care plan as necessary. The resident should be added to the facility wound tracking list and should be seen for weekly wound rounds. Wounds would be measured and assessed weekly and documented in the resident's electronic health record. Any wound identified as worsening would be reviewed by the physician and treatment changes made as indicated. The resident's care plan would be updated to reflect the deterioration. 1) Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/21/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of 2 with bed mobility, dressing, hygiene, toileting, and was dependent for transfers. The resident had two Stage 3 (full thickness tissue loss) pressure ulcers present on admission. The 2/15/22 Admission/Readmission Evaluation completed by licensed practical nurse (LPN) #8 documented the resident had pressure ulcers to the right and left heels, and a contusion (bruise) to the buttock. The resident required moderate to maximum assistance with moving; frequently slid down in the bed or chair and required frequent repositioning with maximum assistance. The resident required extensive assistance of 2 for bed mobility, extensive assistance of 1 for toileting and dressing, and was incontinent of bladder and bowel. The comprehensive care plan (CCP) initiated on 2/16/22 documented a goal of improving skin integrity and wound healing. Interventions included monitor skin condition and reassess as ordered and a supplement, ProStat AWC (a protein supplement drink) daily, as ordered for wound healing. The CCP did not include documentation related to activity of daily living (ADL) needs or pressure relief. The 2/15/22 facility wound physician #12's progress note documented the resident had a bruise on the left buttock and to apply zinc ointment (protective cream) every shift. The note did not include any measurements or characteristics of the bruised area. The 2/15/2022 to 3/1/2022 physician orders did not document any treatments, pressure relief, or monitoring for the resident's buttocks. There was no documented evidence the zinc ointment was ordered as recommended. The 2/15/22 Wound Documentation note by the Assistant Director of Nursing (ADON) #1 did not document the resident had bruising on their buttocks. The 2/23/22 at 4:27 AM, Skin Monitoring note by LPN #10 documented weekly skin monitoring was completed and a new skin alteration was noted. There was no further information regarding the skin alteration and the note did not document the location of the skin alteration. The 2/23/22 at 2:27 PM, Wound Documentation note by the ADON #1 did not include documentation related to the resident's buttocks. The 2/2022 Treatment Administration Record (TAR) did not include documentation related to a treatment to the resident's buttocks or evidence the zinc ointment was ordered or administered as recommended on 2/15/22. The 3/1/22 at 1:55 PM, Wound Documentation note by ADON #1 documented a Stage 3 (full thickness loss of skin layer) pressure ulcer on the left buttock that measured 1.0 centimeter (cm) x 0.8 cm x 0.1 cm. There was a moderate amount of serous exudate (watery drainage) and the wound deteriorated. A treatment was not documented. Interventions included repositioning, resident education, and the CCP was updated. There was no documented evidence the resident's CCP was updated. The 3/1/22 facility wound physician #12's note documented the resident had a full thickness wound of the left buttock that was present for greater than 14 days. The left buttock wound was 1 cm x 0.8 cm x 0.1 cm, there was moderate serous exudate and 100% slough (moist yellow dead tissue). The wound deteriorated and was debrided (removal of dead tissue). The 3/1/22 physician's order documented to the left buttock, cleanse with normal saline, apply [MEDICATION(S)] (treatment) to wound base, cover with a foam dressing daily and as needed. This was the first documented treatment to the resident's left buttock since admission on 2/15/22. The 3/2/22 at 10:00 PM, Skin Monitoring note entered by LPN #10 documented a new skin alteration was noted and there was skin breakdown to the buttocks. The Kardex (care instructions) in place from the resident's admission 2/15/22 through discharge on 3/7/22 documented a skin observation was to be completed every day. There was no documentation the resident had any intervention for pressure relief or turning and positioning. In a telephone interview on 6/22/22 at 11:30 AM LPN #8 said that LPNs would do the admission evaluation and then an RN went in behind them and do any assessments. Once the admission assessment was done, they would report off to the RN or ADON and they would take care of the assessment and CCP. They did not recall the bruise to the resident's buttocks and did not recall any interventions. LPN #8 stated that if they had seen it, they would have reported it to the RN after the admission evaluation. They stated that RN #11 wound nurse used to work a couple of days a week and would do wound rounds with the facility wound physician. On 6/22/22 at 12 PM, facility wound physician #12 stated in an interview that a bruise was noted on the resident's left buttock, it could have been a deep tissue injury (DTI) but was hard to tell at first. The initial bruise/contusion became a Stage 3 pressure ulcer over 2 weeks and required [MEDICATION(S)]. Interventions should have been in place, such as turning and positioning, offloading or an air mattress, and monitoring. The area should have been monitored and zinc applied every shift. If the zinc was applied every shift, someone would have been looking at the area to see if was changing. They stated a nurse would usually round with them, and if there were orders the attending would usually agree and they would be entered by someone at the facility, usually within a few hours. On 6/29/22 at 3:15 PM, LPN #9 Unit Manager stated in an interview, the resident had wounds so they should have had a CCP regarding skin breakdown. When a resident had wounds, it was important to have a CCP to prevent the wounds from worsening and to promote healing. They stated the ADON, or RN usually updated the CCP. In a 7/14/22 at 9:18 AM telephone interview certified nurse aide (CNA) #37 stated if a resident had a bruise or skin breakdown, they would notify the nurse. As a CNA, they would notify the nurse if there was any new bruise or skin breakdown, and the nurse would get orders or tell them what to do for the area. They stated that it was standard practice to reposition the residents every 2 hours, especially for the residents who did not get out of bed. Repositioning helped to relieve pressure. They stated they always looked at the resident care card (Kardex) before providing care to a resident. Most residents had a barrier cream in their room, but they checked the Kardex before they applied it and went by what the Kardex documented. They stated the risk of not using a barrier cream would be the resident could get skin breakdown or irritation. In a 7/15/22 at 8:30 AM telephone interview the ADON #1 they stated there were certain sections on the admission assessment that was completed by LPNs and specific sections that needed to be completed by an RN, such as the section on skin and wounds. The RN used that information to help make the care plan. At the time Resident #5 was in the facility, they had a wound nurse who rounded on the residents and completed their treatments. On the 2/15/22 wound assessment, they stated they were unaware there was any contusion or bruise to the resident's buttocks. If there was a contusion or bruise, it should be tracked like any wound. They were not sure why the recommendation of zinc made by the physician wound consultant was not ordered. When a new area was noted, the area should be assessed and documented in the medical record. They were not sure why there was nothing documented in the wound rounds or notes regarding the left buttock bruise/contusion. They stated the area should have been tracked and there should have been care plan interventions in place. The RN who completed the admission assessment was responsible for putting these in the care plan. They stated something should have been in place from 2/15/22 for the contusion on the buttock and that lack of interventions and monitoring could lead to skin breakdown. On 7/20/22 at 10:54 AM ADON #1 stated that zinc is a barrier cream that came from the pharmacy and required an order. They stated that there were barrier creams that were stocked on the floor that a CNA could apply without an order from a doctor or nurse. They stated if they are applying any barrier cream, it should be put on the TAR. 2) Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/9/21 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance with activities of daily living (ADL), and had 2 unstageable (full thickness tissue loss with wound bed covered by necrotic tissue) pressure ulcers and 2 deep tissue injuries (DTI, injury to underlying tissue). The 11/3/21 registered nurse (RN) #15's admission assessment documented the following skin impairments: - the sacrum had an unstageable pressure ulcer measuring 3 centimeters (cm) x 2 cm with 100% slough (moist yellow dead tissue) to the wound base. - the coccyx (tailbone) had an unstageable pressure ulcer, measuring 4 cm x 4 cm with 90% slough, 10% epithelial (new outer layer of skin) to wound base edges. A 11/3/21 physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not include where the ointment was to be applied or any additional wound care dressings. There was no documentation of physician ordered treatments for either of the resident's pressure ulcers from 11/3/21 through 11/5/21. The 11/4/21 comprehensive care plan (CCP) documented: - The resident was at risk for pressure ulcers. Interventions included: educate, minimize moisture, monitor nutritional status, heel protectors, alternating pressure mattress on bed, pressure cushion in chair. - The resident had an alteration in skin integrity with an actual Stage 4 sacrum. Interventions included: weekly wound assessments, monitor dressing daily to ensure intact, monitor infection, monitor/document, and report to physician changes wound status including wound size. The History and Physical by physician #22 dated 11/6/21 documented the resident had a Stage 2 (partial thickness tissue loss) sacral/coccygeal ulcer. The plan included to continue wound care and did not include recommended treatments for the sacral/coccygeal ulcer. The 11/2021 TAR documented: - 11/5/21, Santyl to sacrum/coccyx was not initialed as completed. The order was discontinued the same day; - 11/6 to 11/8/21, Santyl to sacrum and coccyx and cover with ABD was initialed as completed. The 11/8/21 Initial Wound Evaluation and Management Summary by facility wound physician #12 documented: - an unstageable (due to necrosis, dead tissue) pressure ulcer to the sacrum present on admission. The wound measured 3.2 centimeters (cm) x 3 cm x 0.1 cm, had moderate serous exudate, and 100% necrotic tissue. The dressing treatment plan included Leptospermum honey, apply once daily for 30 days, skin prep (protectant) to the peri wound, gauze island with border as secondary dressing, offload wound, reposition per facility protocol, Group-2 mattress (pressure reduction), Vitamin C, zinc sulfate, and Roho (pressure reduction) cushion in chair. The wound was surgically debrided and healthy bleeding tissue was observed. - an unstageable (due to necrosis) pressure ulcer to the coccyx present on admission. The wound measured 3.5 cm x 3.5 cm x 0.1 cm, had moderate serous drainage, and 100% necrotic tissue. The dressing treatment plan included Leptospermum honey, apply once daily for 30 days. skin prep (protectant) to the peri wound, gauze island with borders secondary dressing, offload wound, reposition per facility protocol, Group-2 mattress, Vitamin C, zinc sulfate, and Roho (pressure reduction) cushion in chair. The wound was surgically debrided and healthy bleeding tissue was observed. The 11/2021 TAR documented: - 11/9 to 11/22/21, [MEDICATION(S)] (wound treatment) to sacrum and coccyx and cover with ABD was initialed as completed every day. There were no corresponding physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] The 11/23/21 RN #11's (former wound nurse) assessment documented: - Coccyx, due to deterioration of the wound, it extended into the sacrum and was now being called a sacral pressure ulcer. - Sacrum, measuring 12 cm x 3.3 cm x 1 cm, Stage 3 pressure ulcer. Deteriorated with tunneling, large serous (watery) drainage and 100% eschar (black dead tissue). Change dressing to wound cleanser moistened Kerlix (dry dressing) into wound with ABD (abdominal pad, absorbent dry dressing) twice daily. The November TAR from 11/22 to 11/29/21 documented wound cleanser moistened Kerlix packed into sacral wound and covered with ABD two times daily. The treatment was not documented as administered on 11/24 days, 11/26 days, and 11/29/21 days. There were no corresponding nursing notes on the missing treatment days. The 12/2/21 at 10:55 AM LPN #8 progress note documented the resident had a foul odor from their sacral wound. The physician was updated, and a culture of the resident's wound was obtained. The 12/6/21 lab reported documented the resident's wound culture of the sacrum grew [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)], resistant bacteria). The 12/6/21 facility wound physician #12's progress note documented the resident had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer on the sacrum that measured 11.5 cm x 5 cm x 1.5 cm with undermining (erosion under ulcer border) of 4.2 cm at 9 o'clock with 30% necrotic tissue and 70% granulation (healthy tissue). The wound deteriorated. The note documented to transfer the resident for surgical consult. Use gauze roll moistened with wound cleanser, and cover with ABD daily. The resident was sent to the hospital. The 12/14/21 hospital discharge summary documented the resident had surgical debridement of their sacral wound and Wound V.A.C. (vacuum assisted closure) placement. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/14/22 updated CCP documented the resident was at risk of pressure ulcers and risk for infection. Interventions included turning and positioning, [CONDITION(S)] in sacral wound, aseptic (medically clean) wound care. The 12/15/21 readmission physician orders documented: - Wound V.A.C. at 125 mmHg to sacral wound. Change on Monday, Wednesday, and Friday. - if wound V.A.C. failed, use wet to dry daily. These orders were discontinued on 12/21/21. The December 2021 TAR documented: - 12/15 to 12/27/22, Wound V.A.C. at 125 mmHg to sacral wound, change 3 times weekly was not documented as completed on 12/15, 12/22 and 12/27, the resident refused on 12/20 and the resident was not available on 12/24/21. - if wound vac fails, use wet to dry dressing, change daily every 24 hours as needed for wound vac fails. There was no documentation wet to dry dressings were used on 12/15, 12/20, 12/22, 12/24, or 12/27/21. The 12/19/21 at 6:26 AM nursing note documented Wound V.A.C. noted to be leaking heavily. Attempt to reinforce was not successful. As needed wet to dry applied per order. The TAR did include documentation a wet to dry dressing was used on 12/19/21 when the Wound V.A.C. leaked. The 12/20/21 facility wound physician #12 documented: - Sacrum, Stage IV, 11 cm x 6.5 cm x 1 cm, undermining of 2 cm at 3 o'clock, 90% granulation (healthy tissue), 10% fascia/muscle, improved. Resident initially refused visit. The resident's Wound V.A.C. had difficulty getting and maintaining seal due to resident's loose skin and lack of subcutaneous tissue. It was safer to proceed with wet to dry. Start Kerlix moistened with wound cleanser, covered with an ABD daily. The 12/2021 TAR documented the Kerlix moistened with NS pack into sacral wound, wipe wound edges with skin prep and cover with ABD. The treatment was documented as not done on 12/24/21 as the resident was out of the facility. The 1/18/22 outside wound specialist #17's note documented: - Sacrum, Stage IV, 10.5 cm x 7 cm x 2.1 cm, undermining started at 9 o'clock and ending at 12 o'clock that measured 2.7 cm. Second undermining started at 3 o'clock and ended at 4 o'clock that measured 1.5 cm. Granulation 67%-100%, necrotic (non-viable tissue) 1-33% slough and necrosis (dead) of bone. The wound was debrided. The note documented to stop wet to dry dressing and start Drawtex, [MEDICATION(S)] Blue and Xtrasorb 3 times per week. Leave bone wax (blood clotting material) and Surgicel (blood clotting material) in place. The note did not document if the dressing was changed during the appointment. The 1/18/21 at 2:10 PM LPN #8 note documented the resident saw outside wound specialist #17 who wanted to leave bone wax and Surgicel in the sacral wound. They recommended Hyrofera Blue placed in wound, covered with Drawtex, and covered with Xtrasorb changed every other day and as needed for drainage or if not intact. The wound specialist was concerned of a possible fistula (an abnormal connection between body parts) developing from the wound to the rectum. Reviewed by physician who was accepting of orders. There was no physician order the treatment was changed to [MEDICATION(S)] Blue, Drawtex and Xtrasorb. The 1/2022 TAR documented Kerlix dressing moistened with normal saline (NS) packed into the resident's sacral wound and covered with an abdominal pad (ABD) every day shift was completed on 1/18/22 and 1/19/22. The 1/19/22 nursing wound assessment by LPN #13 documented: - Sacrum, Stage 4, 11.6 cm x 7 cm x 3 cm, 75% granulation tissue, 25% slough, no change. Treatment: leave bone wax and Surgicel in place. Place Hydrafera Blue in wound bed, cover with Drawtex and Xtrasorb. The 1/20/22 physician orders documented: - discontinue Kerlix moistened with NS packed into sacral wound. - leave bone wax and Surgicel in place. Place Hydrafera Blue in wound bed, cover with Drawtex and Xtrasorb and change every other day. The January 2022 TAR documented Hydofera Blue covered with Drawtex and Xtrasorb every 2 days with a start date of 1/20/22. On 1/20/22 the treatment documented 9 (other/see nurse notes). On 1/22/22, the treatment was not initialed as completed. A nursing progress note by LPN #13 dated 1/20/22 documented wound bed does not have bone wax or Surgicel. Supplies not available Drawtex and Xtrasorb, wound had been packed with gauze soaked in NS and covered with border gauze. There was no documentation there was a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] The 1/24/22 outside wound specialist #17 documented the resident's sacrum pressure ulcer was 10 cm x 7 cm x 3 cm. There was a wet to dry dressing in place when seen. The wound had a small amount of slough and bone/fat layer were exposed. The note documented to STOP using wet to dry dressing and use Drawtex, [MEDICATION(S)] Blue, and Xtrasorb 3 times per week. On 1/25/22, the resident was admitted to the hospital for issues not related to pressure ulcers. On 6/27/22 at 11:51 AM, LPN #13 stated in a telephone interview, when they documented 9 on the administration record that meant other, and they had an option to enter a progress note. If a treatment was newly ordered and not available, they should call the facility's wound physician for an alternate order. On 1/22 and 1/24/22, the resident's [MEDICATION(S)] Blue and Drawtex were not available, they called the Supervisor and believed the Supervisor told them to pack the resident's wound with NS until the treatment was available. They were not sure if the Supervisor called for orders. On 6/27/22 at 12:36 PM, ADON/current wound nurse stated in a telephone interview it was their expectation when a treatment was not available, staff should use a backup order if one was available, or they needed to notify the physician for an alternate treatment. A progress note should be documented to show what the nurse ended up doing when the ordered treatment was not available. When orders were obtained from the physician, they expected them to be implemented within 24 hours. On 6/29/22 at 1:42 PM, RN #15 stated in a telephone interview, when a resident was newly admitted and had pressure ulcers, they expected orders to be obtained within a few hours. They stated in the past, in sometimes took upwards of 72 hours to get orders implemented. They did not recall the resident and did not recall why there were no orders for their pressure ulcer upon admission in November. They stated they were a new employee at the end of October 2021, and they were not trained at that time. On 6/30/22 at 10:19 AM, LPN #8 stated in an interview to get a medication/treatment from the pharmacy, the order was entered into the electronic record and was automatically transmitted to the pharmacy. The medication treatment should arrive at the facility within 24 hours. [MEDICATION(S)] Blue was a specialty order from the pharmacy, was not stocked by the facility and typically took 24-48 hours to be obtained. If the treatment was not available, the physician should be called for an alternate order. On 7/21/22 at 9 AM, physician #22 stated in a telephone interview, when the resident saw outside wound physician #17 on 1/18/22, the treatment order should have been changed and they were not sure why it was not. Facility wound physician #12 either called them directly with recommendations or staff communicated the recommendations to them. Orders should be obtained and implemented immediately or no later than 12 hours. They usually agreed with facility wound physician #12's and outside wound physician #17's recommendations because they were the wound experts. The wound physician would usually call them and discuss the orders, the wound physician would then call a nurse with their orders and physician #22 would approve the orders. If treatments were not available, the staff should notify them to come up with a plan to proceed. They were not aware the treatment was not available from 1/20 to 1/24/22 and when the nurse applied a wet to dry dressing without an order, they should have called them for an order prior. 10NYCRR 415.12(c)(2)

Based on interview and record review during the abbreviated survey (NY 266) conducted 3/24/21 to 4/13/21, the facility did not ensure a resident who needs respiratory care was provided such care consistent with professional standards of practice for 1 of 3 residents (Resident #1) reviewed. Specifically, - Resident #1 was admitted to the facility with hospital discharge orders for a continuous positive airway pressure machine ([CONDITION(S)], device that administers air through the nose at a predetermined level of pressure) that was not implemented at the facility. - The resident did not receive [CONDITION(S)] for the 5 nights they were at the facility and experienced low oxygen levels and respiratory distress. - When oxygen levels were low, a Bi-level positive airway pressure machine ([CONDITION(S)], a device that allows high pressure during inhalation and low pressure upon exhalation) was applied to the resident without orders or parameters for its use and it was applied incorrectly. The resident was transferred to the hospital. This resulted in actual harm to Resident #1 who was transferred to the hospital and admitted for acute care on chronic respiratory failure. Findings include: The 8/2019 Admission-Readmission Policy documents: - The Admissions Department in conjunction with nursing and the business office is responsible for obtaining all admission documents to determine: the required level of care, resident needs, including equipment and medication, expected length of stay, billing and payment requirements, and the resident's past medical history and psychosocial background. - Nursing is responsible for the clinical review and to determine if any specialized equipment or medications are needed and if the facility is able to meet the resident's medical/physical/social needs. The Respiratory-PAP (positive airway pressure) Equipment policy revised 9/2019 documents: - Verify medical physician orders. The order should state the [CONDITION(S)] pressure, the [CONDITION(S)] order should include the inspiratory and expiratory pressures and a respiratory rate if needed. - Verify the [CONDITION(S)]/[CONDITION(S)] pressure on the machine with the pressure manometer (gauge) and adjust to the patient's prescription. - Ensure there is no air leaking around the patient's mask, especially around the eyes. - If the patient is admitted to the facility with existing equipment, the facility should contact the contracted respiratory therapist (RT) for instruction. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/29/20 discharge Minimum Data Set (MDS) assessment documented the resident's cognition was intact; they did not refuse care; required limited to extensive assistance with activities of daily living (ADL); received oxygen; did not receive [CONDITION(S)]/[CONDITION(S)], and did not receive respiratory therapy services. The 12/24/20 at 1:16 PM, email from the Centralized Admission Specialist sent to Minimum Data Set (MDS) Coordinator, registered nurse (RN) #15, and a group, [Facility] Admit, documented Resident #1 was a new admission. The email attachments included the hospital discharge summary. The 12/24/20 hospital discharge summary documented respiratory/[CONDITION(S)] instructions: [CONDITION(S)] mask type: facial mask; no auto-titrate; PEEP/EPAP (positive end expiratory pressure/expiratory positive airway pressure):12; FIO2 (fraction of inspired oxygen):35; and wean/titrate oxygen (O2) to keep saturations greater than or equal to 92. The 12/24/20 Admission Evaluation by former Director of Nursing (DON) #12 documented the resident had oxygen orders and no breathing treatments or other respiratory treatments. There were no medication/treatment/oxygen order discrepancies and all records matched per discharge records. The 12/24/20 physician #11's admission progress note documented the resident was breathing well, was on 6 Liters per minute (lpm) of oxygen (O2) and a [MEDICATION(S)] (steroid) taper. There was no documentation regarding the [CONDITION(S)] machine. The 12/24/20 admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for the use of a [CONDITION(S)] machine. The 12/24/20 baseline comprehensive care plan (CCP) contained no documentation regarding the use of oxygen or [CONDITION(S)]. The 12/24/20 at 9:45 PM, licensed practical nurse (LPN) #14's progress note documented the resident had O2 at 6 lpm continuously, lungs were clear, and they experienced shortness of breath during activity. Nursing progress notes on 12/25/20 did not include documentation regarding a [CONDITION(S)] machine or its use. The 12/26/20 at 6:17 AM, LPN #14's progress note documented the resident's family member called and stated the resident could not wear the [CONDITION(S)] machine that came from the hospital and needed a machine that was set to the resident's needs. The family member reported the resident may also need [CONDITION(S)] if they became lethargic due to CO2 ([MEDICATION(S)]) buildup in the lungs. The family member would call back to speak to someone regarding the resident's status later and the Supervisor was notified. Nursing progress notes on 12/27/20 and 12/28/20 contained no documentation regarding a [CONDITION(S)] machine or its use. The 12/29/20 at 9:06 AM, DON #12's progress note documented the resident's O2 saturation (amount of oxygen in blood) was low at 83% and the resident was on [CONDITION(S)]. The resident was short of breath, physician #11 was notified, and the resident was sent to the hospital. The 12/2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/29/20 emergency medical service (EMS) report documented they arrived to the resident at 9:23 AM. The resident was short of breath and facility staff reported low O2 levels and that a [CONDITION(S)] was placed 10 minutes prior. The resident was observed lying in bed, was lethargic, and had a [CONDITION(S)] on that was not placed properly. O2 saturation was 83%. The emergency medical technicians (EMT) removed the [CONDITION(S)] as there was not a good seal as the mask was too small for the resident. The EMTs applied 15 lpm O2 to the resident and O2 saturation increased to 90%. The resident was transferred to the hospital. The hospital History and Physical dated 12/29/20 documented the resident was admitted with acute on chronic hypercapnic (too much [MEDICATION(S)] in the blood) respiratory failure. The primary cause was documented as being due to the resident not having positive pressure ventilation for 5 nights at the nursing facility ([CONDITION(S)]). The resident was admitted to the hospital for treatment including [CONDITION(S)]. LPN Manager #8 stated in an interview on 3/25/21 at 1:40 PM, when new admission paperwork was received, the Supervisor reviewed the orders and called the physician. Any changes by the physician were noted on the hospital discharge instructions and all orders were entered into the medical record including orders for [CONDITION(S)] or [CONDITION(S)]. LPN #8 stated she noticed there were no orders for the resident's [CONDITION(S)], she asked DON #12 about it, and he was checking into it. She did not know if the resident received [CONDITION(S)] while at the facility. During an interview with the resident's health care proxy (HCP) on 3/27/21 at 8:00 AM, she stated: - the resident did not have a [CONDITION(S)] machine at the time of admission to the facility and required it every night. - on their first night at the facility, DON #12 told her she had to provide a [CONDITION(S)] machine. - the next day, the HCP brought a [CONDITION(S)] machine to the facility and gave DON #12 the name and number of the physician at the medical equipment company to speak to about the [CONDITION(S)] settings, if they were not in the hospital discharge instructions. - DON #12 called her later that night and stated he was not able to locate any settings for the machine. - on the third day, DON #12 told her the [CONDITION(S)] machine was set up but he did not know the settings. The HCP gave DON #12 the name and phone number of the company to call and reiterated the importance of the resident having [CONDITION(S)] at night. - Later that day, DON #12 told her the [CONDITION(S)] was set-up. - on the morning of 12/29/20, LPN #14 called and said the resident was having difficulty breathing and asked what to do with the [CONDITION(S)] machine. The HCP told LPN #14 the resident now needed [CONDITION(S)] because when in respiratory distress, the resident was unable to push air out. She told LPN #14 to get a RN and a [CONDITION(S)] machine and she was coming to the facility. - she arrived at the facility and talked to DON #12 through the resident's window. She attempted to guide DON #12 on applying [CONDITION(S)]. DON #12 told her they were sending the resident to the hospital. - the HCP stated the resident told her the [CONDITION(S)] machine was never set-up or used while they were at the facility. During an interview with MDS Coordinator/RN #15 on 4/2/21 at 10:36 AM, she stated she received emails from the corporate office about new admissions and the department managers also received the same email. The 12/24/20 email regarding Resident #1's admission, included the hospital discharge paperwork. It was the responsibility of the applicable department managers to ensure the needed equipment and/or treatments were available for the incoming resident. Nursing (DON or Supervisor) were responsible to ensure the equipment was available and to verify orders with the physician. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #15 did not know if the resident arrived with their own [CONDITION(S)] and stated the facility could obtain a machine if needed. She did not know if the resident used [CONDITION(S)] while at the facility and recalled one meeting where the settings were discussed, but she did not know the outcome. During a telephone interview on 4/5/21 at 10:41 AM, LPN #14 stated she thought the resident arrived to the facility with a [CONDITION(S)] machine and DON #12 said the settings were wrong. LPN #14 thought DON #12 called the respiratory therapist (RT) about it. LPN #14 stated the [CONDITION(S)] machine was in the resident's room during their stay but was not used because they did not know the settings. On 12/29/20, the resident's daughter was at the window because the resident was not doing well. The daughter was directing LPN #14 on what to do and told LPN #14 the resident needed [CONDITION(S)]. LPN #14 and DON #12 went to the basement and retrieved a [CONDITION(S)] machine and DON #12 placed it on the resident. To her knowledge, 12/29/20 was the first time a [CONDITION(S)] or [CONDITION(S)] machine was placed on the resident while they were at the facility. During an interview with DON #12 on 4/7/21 at 2:00 PM, he stated he was the admitting RN and DON when Resident #1 was admitted . The resident did not arrive with a [CONDITION(S)] machine, the DON was aware of orders for [CONDITION(S)] usage, and he called RT #15 the evening the resident was admitted . RT #15 guided him through setting up the facility's [CONDITION(S)] machine and he did not document the call. The resident's daughter brought in another [CONDITION(S)] machine, the resident did not like it, and it was not used. He should have obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He did not recall speaking to the physician about the [CONDITION(S)]. When he placed the resident on [CONDITION(S)] on 12/29/20, he used the same [CONDITION(S)] machine the resident had in the room. DON #12 stated the machine could be used as a [CONDITION(S)] or [CONDITION(S)] and he did not have to change any settings to do this. The resident's daughter guided him through the window on how to place [CONDITION(S)] on the resident. DON #12 realized the resident was not improving so he called the physician for an order to send the resident to the hospital. During an interview on 4/7/21 at 4:00 PM, with the Regional Clinical Director/DON #19, she stated an order was needed for [CONDITION(S)] or [CONDITION(S)] use. She stated typically admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated this process was not followed in 12/2020. DON #12 was the admitting nurse and was responsible for ensuring the orders were entered and reviewed, however DON #12 also completed the admission, and this may be the reason there was no follow-up verification. During a telephone interview with RT #15 on 4/9/21 at 9:50 AM, he stated he did not recall speaking to DON #12 about Resident #1 and had no documentation that he provided any consultation about Resident #1. RT #15 stated the [CONDITION(S)] settings on Resident #1's hospital discharge orders were not appropriate for the machines at the facility they would have had to be adjusted. RT #15 stated a machine can be used as both [CONDITION(S)] and [CONDITION(S)], but the settings were different. RT #15 stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview with the attending physician on 4/13/21 at 3:51 PM, he stated the staff reviewed the discharge orders from the hospital with him and then placed in the medical record. The physician expected the facility to be prepared for the resident's needs, including any needed equipment. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the facility had difficulty clarifying the settings or had other issue, he wanted to be notified immediately. He was unaware the resident had hospital discharge orders for [CONDITION(S)] and if he had known there was difficulty in setting up the machine or implementing it, he likely would have sent the resident back to the hospital. After the resident's admission, the physician was not contacted about the resident until the morning of 12/29/20 when the resident was in respiratory distress and being sent to the hospital. He was unaware if the resident used the [CONDITION(S)] during their stay at the facility. When the resident went into respiratory distress on 12/29/20, he should have been notified prior to the staff using the [CONDITION(S)] and he was not aware [CONDITION(S)] was used. He stated if he was notified, he typically would order an arterial blood gas (ABG, measures the oxygen and [MEDICATION(S)] in the arteries) prior to ordering a [CONDITION(S)]. 10NYCRR 415.12 (k)(6)

Based on record review and interview during the abbreviated survey (NY 275) the facility did not ensure residents had the right to be free from abuse, neglect, mistreatment, and involuntary seclusion including corporal punishment and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 of 3 residents reviewed (Resident #2). Specifically, Registered Nurse (RN) #5 wrapped his arms around the resident, slid the resident to floor, and settled on top of the resident with his body weight restricting Resident #2's movement. The resident sustained [REDACTED]. This resulted in actual harm to Resident #2 that was not immediate jeopardy. Findings include: The facility's Unmanageable Resident Policy revised 11/2019 documents: - If a resident becomes abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his/her safety or safety of others, the Supervisor must immediately provide for safety of all concerned (move resident, equipment, etc.), and notify the physician, Director of Nursing (DON), and resident representative. - If the resident poses an immediate danger, or becomes violent or beyond control of the facility, local law enforcement agencies may be called for assistance. The facility's Abuse Policy, revised 12/2019 documents: - The definition of abuse includes unreasonable confinement, intimidation resulting in physical harm, pain and/or mental anguish; punishment resulting in physical harm or pain or mental anguish. - Physical abuse includes controlling behavior through corporal punishment. - The facility will provide training for employees through orientation and bi-annually which will include utilization of appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. The Falls Management and Prevention Policy, revised 1/2020 did not document the appropriate way to transfer a resident off the floor following a fall. Resident #2 had [DIAGNOSES REDACTED]. The 3/23/20 Minimum Data Set (MDS) assessment documented the resident's cognition was intact and the resident made consistent and reasonable decisions. The resident did not exhibit behaviors towards others and did not reject care or wander. The resident required extensive assistance of two people for activities of daily living (ADL) and had upper and lower extremity impairment on one side of the body. The comprehensive care plan (CCP) dated 3/20/20 documented the resident required extensive assistance with ADLs including extensive assistance from 2 persons with transfers related to one-sided weakness and had communication difficulty related to [MEDICAL CONDITION]. Interventions included communication techniques which enhanced interaction, allow the resident time to respond, do not rush, face resident, ask yes/no questions. Nursing and social services progress notes from 3/22/20 to 4/16/20 documented one occasion where the resident was combative with staff on 4/6/20. On that date, a second certified nurse aide (CNA) was asked to assist with care. The resident was hitting at the staff and they reminded the resident they were there to help with care so the resident could go home. No other behavioral issues/concerns were noted. The 4/17/20 licensed practical nurse (LPN) Manager #7's progress note at 6:00 PM, documented: - At around 2:15 PM, the resident motioned to the door, which the LPN came to understand as the resident's desire to go home. The LPN told the resident they were not safe to go home at present. The resident got angry, threw water, and cleared items from the counter. The LPN redirected and the resident became more agitated and returned to their room. LPN #7 told staff to give the resident space to calm down. - At around 2:35 PM, a CNA reported the resident elbowed her and was throwing things in their room. Staff were told to keep a distance and registered nurse (RN) #5 went to talk to the resident. - A short time later, RN #5 and LPN #7 responded to a page and she heard a lot of commotion at the front door. The resident was trying to get to the front door, trying to run the wheelchair into anyone in the way, and was swinging at anyone nearby. - RN #5 told the resident to stop hitting, attempted to calm the resident, and wrapped his arms around the resident. The resident continued to try and hit, and RN #5 slid the resident to the floor, partially lying across the resident's side. The resident agreed to stop hitting and was helped back into the wheelchair. The resident was upset and agitated and swung out at people and the staff relocated the resident from the door. - RN #5 notified the physician and received an order for [REDACTED]. - At around 3:30 PM, a CNA told LPN #7 the resident was tearful and had right hip pain. LPN #7 observed the resident in the wheelchair, leaning to the left and crying. Upon palpation of the hip and back, the resident grimaced and pulled away. The resident could not tolerate the right leg being moved, which was abnormal from baseline. The resident was offered assistance to bed and refused due to pain. An ice pack was offered and accepted by the resident. LPN #7 immediately reported the concern to RN #5 and the Director of Nursing (DON). When interviewed on 11/19/20 at 2:50 PM, LPN Manager #7 stated on 4/17/20: - She and RN #5 were paged to the front area of the building. The resident was very upset and agitated and as RN #5 was approaching the resident, he was yelling that if the resident did not stop, he would take him to the ground. LPN #7 stated before I knew it, he did. - LPN #7 stated RN #5 put his arms around the resident, it looked like a bear hug, and then the resident and RN #5 went down to the ground and RN #5 laid across the resident's body. RN #5's actions happened so quickly, as soon as he arrived on the scene and she was walking behind him to the scene. - LPN #7 continued to state, she did not see if the resident was hitting anyone and the resident did not have any objects in their hands that they were throwing or hitting people with. - When on top of the resident, RN #5 asked the resident if they were going to calm down, and LPN #7 knelt by the resident on the other side and tried to talk to the resident, who nodded. - There were a lot of commotion and a lot people around and she did not think the resident had an opportunity to calm down because people were not backing off and giving the resident space. RN #5's action was almost immediate upon his arrival to the scene. - The resident was assisted back in the chair by LPN #7 and 2 or 3 other staff. LPN #7 was behind the resident when they picked the resident up. She stated they either went under the resident's arm or grabbed their pants to lift them. - One of the CNAs took the resident down toward their room, and the resident was tearful. A short time later, a CNA reported the resident was in pain, the LPN evaluated the resident who made it clear they were in pain. - She stated the resident had no history of behaviors and had never hit staff prior. She stated she would have expected staff to provide the resident space, ensure the resident did not have objects that could harm themselves or others, move other residents away, and then re-approach later when the resident was calm. She stated a physical hold or putting a resident on the floor was not a means to calm an angry resident as this could be considered a restraint and could possibly cause injury. The 4/17/20 police report documented at 2:30 PM, they were at the nursing facility for an unrelated issue and observed RN #5 on top of the resident on the floor. The RN was asking the resident if he let them up, would they stop hitting the nurses? When the resident calmed down, they were placed back in their wheelchair, pointing to the door, making sounds, and the officer noted it was obvious they wanted to go out. The officer observed staff trying to wheel the resident to their room and the resident resisted by holding the left wheel of the wheelchair with their hand. The officer noted when the resident did this, staff would forcibly pry the resident's hand off the wheelchair wheel. The officer noted eventually the staff backed away and got permission to give the resident a sedative and the officer left the facility. The emergency medical services (EMS) report documented they arrived at the facility on 4/17/20 at 4:16 PM: - Upon arrival, EMS was told by a staff, patient became combative and I slammed him to the ground on his right side pretty hard and now he is complaining of hip pain. - EMS observed the resident on the bed in fetal position. The resident pointed to their hip and said ow. - An assessment was attempted, and EMS thought there was shortening of the limb but had difficulty assessing due to pain. Swelling and deformity were noted. A CNA, who assisted with positioning the resident, reported the resident was slammed pretty hard and she thought something was broken or dislocated. The resident was transported to the local hospital. During a telephone interview on 11/20/20 at 12:14 PM, paramedic #18 stated she arrived at the facility on 4/17/20 for a resident complaining of back pain. Upon arrival, RN #5 informed her the resident had been belligerent and was swinging at staff and others and he picked up the resident and slammed the resident down. RN #5 admitted to slamming the resident hard. She observed the resident in bed, in a lot of pain, and had deficits on one side of the body. When RN #5 left the room, CNA #11 told the paramedic the nurse slammed the resident very hard. The paramedic stated CNA #11 told her RN #5 was more forceful than needed. Paramedic #18 stated the resident was known to her from the community, had deficits on one side of the body, was in a wheelchair, and was not a threat to facility staff. A second 4/17/20 EMS report documented at 8:07 PM, the resident was transferred from the local hospital to a larger medical center where they could receive treatment to the right femur fracture. During a telephone interview on 11/23/20 at 4:20 PM, CNA #11 stated on 4/17/20: - she was in the vestibule at the facility entrance screening oncoming staff when she heard the resident yelling you you you which is what the resident said when angry. She saw the resident hitting staff and trying to get out the interior door, leading to the vestibule. - RN #5 arrived on the scene and told the resident to stop or he was going to have to take the resident out of the wheelchair. The resident calmed momentarily, then resumed hitting at staff. Every time RN #5 tried to move the resident's wheelchair; the resident lashed out. RN #5 held down the resident's left arm, told them to calm down, and said he was going to have to put the resident on the floor. The resident was going to go back to their room, then swung at RN #5, who said, that's it and moved the resident to the floor. She stated the DON was present when RN #5 threw (the resident) on the floor. - CNA #11 described the event as RN #5 picking up the resident and putting them on the floor. CNA #11 stated when RN #5 picked the resident up, the resident's right leg twisted and then the resident went down on their hip. RN #5 had a knee up against the resident on the floor, laying lateral to the right hip, RN #5's knee was up against the resident's hip and buttock. The resident was lying on their right side, facing away from RN #5. They were on the floor for approximately 5 minutes, all the while, RN #5 was holding the resident. During a telephone interview on 12/10/20 at 11:39 AM, CNA #13 stated on 4/17/20 at around 2:30 PM, the resident was in their room hitting and kicking their room door and the resident elbowed her when she was near them. CNA #13 reported it to LPN #7, who instructed her to leave the resident alone. RN #5 was called by LPN #7 and when he approached the resident's room, she heard him saying I'm not going to deal with this (expletive). The resident continued to yell at RN #5 and RN #5 left the room. A little while later, the resident was at the front door and staff were trying to pull the wheelchair back and the resident was swinging at them. RN #5 arrived and told the resident to stop hitting people. CNA #13 went to get the police officer (who was in the building for an unrelated issue) and when she returned, RN #5 and the resident were on the floor. RN #5's body was partially on top of the resident's body, while their arms and legs were restrained by the RN #5. The resident was yelling you you you. RN #5 told the resident they could not hit his staff and asked if the resident was ready to calm down. The resident nodded yes, and staff put the resident back up in the wheelchair. During telephone interviews on 12/10/20 at 2:00 PM and again at 5:12 PM, RN #5 stated: - He had minimal interaction with the resident prior to the events on 4/17/20. - The resident had difficulty communicating due to a prior stroke and was frustrated as a result and had no behavioral issues prior to 4/17/20 that were not redirectable. - On 4/17/20, RN #5 was called to the resident's unit, who was agitated in their room and threw some items. Approximately 10 minutes later, RN #5 received a page to the unit and the resident was in the wheelchair near the front door and had LPN #15 pinned against the door with their wheelchair, swinging aggressively at the LPN. - It was at that point he decided to do a takedown which he described as placing his arms around the resident, lifting the resident up over the arms of the wheelchair, and placing himself and the resident onto the floor. Once on the floor, he continued to hold the resident from behind, restraining the resident's arms. He stated they were both lying on their sides. - RN #5 stated prior to putting the resident on the floor, he felt the resident was at risk of falling. - Once on the floor, he asked the resident if the resident was calm and if they wanted to be let back up in the chair, and he and other staff lifted the resident back into the chair. - RN #5 stated his response was immediate as there were many people around, everyone was escalated, and he wanted to diffuse the situation. He was unsure of what to do in that situation and referred to his knowledge and experience in a psychiatric setting doing a rapid takedown where the nurse explained expectations and outcome while providing the least restrictive physical intervention. - RN #5 received no training at the facility for any such intervention and was unaware of their behavioral intervention policy. - RN #5 stated in retrospect, the technique he used was not the least restrictive intervention to utilize and he could have attempted to clear the area, stand in front of the nurse, or just take a deep breath and give it moment to assess. In that moment, he did only what he knew to do from his psychiatric nursing experience and unfortunately it resulted in the resident getting injured. During a telephone interview on 12/11/20 at 10:05 AM, attending physician #16 stated a takedown was never appropriate in a long-term care setting and he was unaware it occurred. He stated any type of hands on restraining was not acceptable and could cause harm to a resident. The intention was to prevent harm, not cause it. The physician was not made aware of events until the next day and stated it was unfortunate staff made a mistake that led to the resident being harmed. Resident #2 was interviewed on the telephone on 12/11/20 at 11:28 AM. The resident was assisted by their personal care aide (PCA #17) who was on the call over speaker phone. The resident agreed to discuss the case in the presence of the PCA and with her assistance. The resident recalled the events on 4/17/20 and was very frustrated and angry that day about wanting to go home. When RN #5 approached them at the door, the resident said RN #5 was calm, but angry. The PCA stated the resident held up their fist to show an angry gesture when clarifying how RN #5's emotional state was at the time. No one asked the resident what they wanted, was only told to stop. If they left the resident alone, they would not have hit at them. When RN #5 put them on the floor, it was about 3 minutes after he arrived and told the resident to stop. It hurt when RN #5 put his arms around and lifted the resident. The resident felt their right-side twist when pulled up out of chair. When the resident landed on the floor with RN #5 it hurt. RN #5 held the resident on the floor and the resident was scared, angry, and in pain. The resident was on the floor being held for 2-3 minutes. When staff picked the resident up to put back in the chair, it was painful, no one asked the resident if there was any pain before being picked up. The DON was interviewed on 12/11/20 at 12:49 PM and stated when he arrived at the scene on 4/17/20, RN #5 was on the floor with the resident. The resident said they were okay, and he told RN #5 to get the resident back in the chair. He stated he did not notify the attending physician of what had occurred, and RN #5 may have done so. He stated if the nurse Supervisor assessed the situation and felt they needed to physically restrain a resident then he agreed with their assessment. He stated RN #5 assessed the situation based on his background as a psychiatric nurse and prior training. He stated in addition to the physical restraint, the RN could have called the physician for guidance. He stated the company had a policy that addressed the use of a takedown in the facility when needed. He stated there was no facility training that he was aware of, he had no documentation that RN #5 was trained, and he referred the surveyor to the Corporate Educator. He stated he would not have done a takedown himself as it could harm a resident. The DON stated the resident had no prior behaviors and was upset that day that they could not go home. On 12/22/20 at 10:51 AM, the Corporate Educator stated in an interview, he did not know why using physical force was in any of the company policies. He stated he revised the Behavior - Managing Emergencies policy in 5/2020 and, meant to remove it but did not. He planned to remove it when future revisions were made. He stated the company did not advocate the use of physical maneuvers in the nursing facilities, did not train staff on using them, and they were not appropriate in long-term care settings as they did not meet the regulations. He stated even if RN #5 had been trained at a prior workplace on the maneuver he used, it should not be used in the nursing facility. An interview was attempted with LPN #15 without success. 10NYCRR 415.4(b)(1)(i)