Every finding on record at Chautauqua Nursing and Rehabilitation Center

Based on interview and record review conducted during the survey the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the Administrator did not provide adequate oversight of the Business Office Manager to ensure adequate accounting and records of personal funds. Additionally, when there was reasonable suspicion of misappropriation of resident funds, it was not reported to the State Agency within the required timeframe.The findings are: REFER TO: F 568 - Accounting and Records of Personal Funds scope and severity F F 609 - Reporting Alleged Violations scope and severity F The policy and procedure titled Financial Affairs dated 10/2016 documented residents may manage his/her personal financial affairs will be given at least a quarterly accounting of financial transactions made on his/her behalf. A separate receipt book is to be maintained for recording withdrawals. Receipts should include the residents name, amount withdrawn, brief description of what it is for and signed by the resident or the power of attorney on file. When reimbursing the Resident Spending Cash Box all receipts are to be added up and the check is made payable to the Business Office Manager for that amount and signed by the Administrator. Statements are required to be sent out on a Quarterly basis to the representatives, so they are aware of activity occurring. Any purchases made by other than the power of attorney or Responsible Party requires a proof of receipt for disbursement from that residents account. Receipt purchases should then be attached to the disbursement receipt and signed appropriately. The policy and procedure titled Facility Incident/Abuse Investigation and Reporting revised 09/2025 documented Residents have the right to be free from verbal, sexual, physical, mental abuse, neglect, mistreatment, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and injuries of an unknown source. Personnel must report any resident incident or suspected incident immediately to Supervisor/Administrator. Applicable incidents will be reported to state agency, adult protective services and to all other required agencies. For allegations of abuse, neglect, mistreatment, misappropriation or once suspicion of abuse has been formed, the Director of Nursing Services must notify the Department of Health as soon as possible, not to exceed two (2) hours. During an interview on 03/27/2026 at 12:10 PM, the Administrator stated Business Office Manager #1 was responsible for sending out quarterly statements and maintaining receipts from the Country Store. They stated keeping records of the personal funds were important because then the families would know what money was being spent on and the receipts would verify what was purchased by the resident at the Country Store. The Administrator stated they or the Director of Nursing were responsible for reporting suspicions of abuse to the State Agency so that the State Agency was aware of any suspicions of abuse. During an interview on 03/27/2026 at 12:24 PM, the Regional [NAME] President stated they oversaw the Administrator. The Administrator was responsible for overseeing Business Office Manager #1. They stated the Administrator would notify them whenever there was anything that should have been reported to the State Agency. 10 New York Code Rules Regulations 415.26

Based on interview and record review conducted during the survey the facility failed to ensure that all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to administrator of the facility and to other officials (including to the State Survey Agency) for six (6) (Resident #18, # 19, #136, #138, #164, and #167) of six (6) residents reviewed. Specifically, the facility did not report to the State Agency when there was reasonable suspicion of misappropriation of resident funds. This resulted in no actual harm with the potential to affect all residents, that is substandard quality of care.The findings are: Refer to F 568 Scope and severity F The policy and procedure titled Facility Incident/Abuse Investigation and Reporting revised 09/2025 documented residents have the right to be free from verbal, sexual, physical, mental abuse, neglect, mistreatment, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and injuries of an unknown source. Personnel must report any resident incident or suspected incident immediately to Supervisor/Administrator. Applicable incidents will be reported to the State Agency, adult protective services and to all other required agencies. For allegations of abuse, neglect, mistreatment, misappropriation or once suspicion of abuse has been formed, the Director of Nursing Services must notify the Department of Health as soon as possible, not to exceed two (2) hours. Review of Resident #18's Trust Statements 01/17/2024 through 02/24/2026 revealed there were 78 documented transactions at the facility's store. Review of Resident #19's Trust Statements 09/10/2025 through 02/24/2026 revealed there were 20 documented transactions at the facility's store. Review of Resident #136's Trust Statements dated 01/03/2024 through 02/16/2026 revealed there were 110 transactions at the facility's store. Review of Resident #138's Trust Statements dated 01/04/2024 through 12/29/2025 revealed there were 105 documented transactions at the facility's store. Review of Resident #164's Trust Statements dated 03/11/2024 through 02/24/2026 revealed there were 94 documented transactions at the facility's store. Review of Resident #167's Trust Statements dated 10/07/2025 through 12/31/2025 revealed there were nine (9) documented transactions at the facility's tore. During a telephone interview on 03/23/2026 at 9:47 AM, the Ombudsman stated residents with personal funds accounts had recently received a letter from the facility regarding an audit that had occurred going back from January 2024 until current. The letter stated that residents were reimbursed for any store purchases, and the record keeping was not up to par. They stated that families were concerned because that was when they found out that residents were withdrawing $80 per week. Review of the undated document titled Country Store Investigation (facility store) the following was documented: -Family member of Resident #167 inquired about purchases related to the Country Store. Administrator reviewed the purchases and was unable to find documentation related to Country Store transactions. -Business Office Manager #1 stated they did not have receipts for the transactions. They acknowledged that they should have the receipts. On 03/27/2026 The Administrator provided a document titled Meeting Minutes from The Chief Human Resource Officer. The document included an interview with Business Office Manager #1 that occurred on 02/19/2026. Business Office Manager #1 had stated to the Chief Human Resource Officer and Regional [NAME] President that they had no independent records from the Country Store in terms of money in/out or transactions. On 03/27/2026 the Regional [NAME] President provided a document titled Summary of Interview with Business Office Manager #1 on 02/19/2026 with The Chief Human Resource Officer. It was documented that Business Office Manager #1 stated they did not keep a receipt book or activities order slips. Business Office Manager #1 acknowledged that there was no way to verify previous purchases and should have kept receipts or activity order slips to verify purchases but did not and was unable to show proof of purchase. During a telephone interview on 03/24/2026 at 9:30 AM, Resident #18's Responsible Party stated Resident #18 was refunded $2300 recently because of an audit that had occurred. They stated they received a letter and were refunded money, which was fine, but the fact that the facility had to audit from January 2024 through February 2026 was concerning that something was going on with the accounts for those two (2) years. On 03/26/2026 at 1:01 PM a call was placed to Business Office Manager #1. The voicemail box was not set up. Business Office Manager #1 did not return the phone call. During an interview on 03/26/2026 at 1:04 PM, the Administrator stated misappropriation was using resident property or money in an inappropriate manner. The Administrator stated Business Office Manager #1 did not keep receipts and was putting in transactions from the Country Store without those receipts. They stated that Business Office Manager #1 was recording transactions based on memory of what the residents had purchased. The Administrator stated they had contacted The Regional [NAME] President, and an investigation was started. They stated The Regional [NAME] President and Chief Human Resource Officer had completed the investigation. During an interview on 03/26/2026 at 1:30 PM, the Regional [NAME] President stated the Administrator had brought the Country Store charges to theirs and the Chief Human Resource Officer's attention. They stated during their investigation both themselves and the Chief Human Resource Officer had interviewed Business Office Manager #1 and residents were also interviewed. The Regional [NAME] President stated Business Office Manager #1 was unable to produce receipts and acknowledged they should have had receipts. They did not follow the proper procedure of recording transactions. When residents were interviewed, some stated they made purchases at the Country Store, and some were unable to recall if they had made any purchases. The Regional [NAME] President stated misappropriation was using resident funds without their awareness. They stated obviously you look at the transactions and ask if misappropriation occurred, but it was not suspected because they were unable to confirm if misappropriation had occurred. The Regional [NAME] President stated because there were no receipts and proper procedure was not followed; Business Office Manager #1 was terminated and transactions to the Country Store were reimbursed. During a telephone interview on 03/27/2026 at 8:53 AM, Resident #167's Responsible Party stated in discussions with the Medicaid Coordinator regarding purchases Resident #167 made at the Country Store they were shocked because Resident #167 had a diagnosis of dementia and would have bought anything that staff had offered to sell them. They stated Resident #167 was somehow spending somewhere between $10-$25 a week at the Country Store. Something was wrong with their record keeping. They stated they were questioning what Resident #167 was buying or if someone was taking advantage of Resident #167's mental state, taking the money or items that Resident #167 was buying. During an interview on 03/27/2026 at 10:34 AM, the Medicaid Coordinator stated that the amount Resident #167 was spending at the Country Store weekly was a red flag to them. They stated this had happened sometime in February, around the week of the 9-13th. The Medicaid Coordinator stated Social Worker #1 was involved and they reported this to the Administrator. If Social Worker #1 was not involved, they would have reported it to the Administrator because something unusual was happening. During an interview on 03/27/2026 at 10:45 AM, Social Worker #1 stated Resident #167's Responsible Party had concerns and they were discussing items that were being purchased at the Country Store. The purchases were all the same amount and were consistently made. Social Worker #1 stated they went to pull the sheet to see what Resident #167 was ordering from the Country Store, but they could not find any ordering sheets or receipts. They stated there were no receipts or accountability for the purchases that were made. Social Worker #1 stated they found out with the Medicaid Coordinator that there were more residents with consistent purchase amounts and frequency. They stated the list of resident names with these purchases all looked very interesting because the residents all had lower Brief Interview for Mental Status scores, ranging from moderate to severe cognitive impairment and the families were not invested as much with these particular resident's care. Social Worker #1 stated if there were receipts to back up the purchases, then it would have made sense but there were none. Social Worker #1 stated that it all looked very suspicious and there could have been some sort of financial abuse happening. After they noticed this, they had brought this to the attention of the Administrator on 02/11/2026. During an interview on 03/27/2026 at 12:10 PM, the Administrator stated Resident #167's Responsible Party was questioning charges from the Country Store on 02/10/2026. They stated that they began looking into the process for residents purchasing items from the Country Store and that was when they discovered the process was very sloppy. The Administrator stated they notified The Regional [NAME] President and Chief Human Resource Officer when they realized there were no receipts. The Regional [NAME] President and Chief Human Resource Officer did a full investigation on all the personal funds accounts; investigating who went to the Country Store and looking to find any verification process. The investigation took approximately one (1) week to complete. They looked for receipts to prove purchases were made at the Country Store and spoke to Business Office Manager #1. The Administrator stated they did not think any misappropriation was happening because even a resident with a lower cognition could buy a candy bar. They stated it would have been reported immediately to the New York State Department of Health if they had any inkling of misappropriation happening. They stated they did not feel this was financial abuse, but instead they felt it was someone who was not paying attention. They stated suspicions of abuse were supposed to be reported to the State Agency so that the State Agency was aware and could complete their investigation as well. During an interview on 03/27/2026 at 12:24 PM, the Regional [NAME] President stated the Administrator notified them on 02/17/2026 regarding the Country Store transactions. The Regional [NAME] President stated during the investigation of the Country Store, it was clear there was a lack of documentation and Business Office Manager #1 was not keeping receipts. Without the receipts it was hard to go back and figure out the transactions that occurred. The Regional [NAME] President stated during the interview with Business Office Manager #1, they kept saying they did not do anything and should have kept the receipts. They stated without the receipts; they could not verify if there was any misappropriation. They stated the Administrator was responsible for reporting abuse. 10 New York Code Rules Regulations 415.4 (b)(2)

Based on interview and record review conducted during the survey the facility failed to ensure the individual financial record was available to the residents through quarterly statements and upon request for six (6) (Resident #18, #19, #136, #138, #164, and #167) of six (6) residents reviewed. Specifically, there was no evidence the facility provided quarterly statements to residents or their representatives and there was no evidence of receipted accounting records for personal fund transactions from the facility's store.The findings are: The policy and procedure titled Financial Affairs dated 10/2016 documented Residents may manage his/her personal financial affairs will be given at least a quarterly accounting of financial transactions made on his/her behalf. A separate receipt book is to be maintained for recording withdrawals. Receipts should include the residents' name, amount withdrawn, and a brief description of what it is for and signed by the residents or the power of attorney on file. When reimbursing the Resident Spending Cash Box all receipts are to be added up and the check is made payable to the Business Office Manager for that amount and signed by the Administrator. Statements are required to be sent out on a quarterly basis to the representatives, so they are aware of activity occurring. Any purchases made by other than the power of attorney or Responsible Party requires a proof of receipt for disbursement from that residents account. Receipt purchases should then be attached to the disbursement receipt and signed appropriately. 1. Resident #18 had diagnoses that included cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) of the left side, and aphasia (absence or difficulty with speech). The Minimum Data Set (a resident assessment tool) dated 01/09/2026 documented Resident #18 was usually understood, usually understands and had moderate cognitive impairment. Review of Resident #18's Trust Statements 01/17/2024 through 02/24/2026 revealed there were 78 documented transactions at the Country Store. 2. Resident #19 had diagnoses that included leukemia (cancer of blood-forming tissues), myelodysplastic syndrome (a group of cancers), major depressive disorder and generalized anxiety disorder. The Minimum Data Set, dated [DATE] documented Resident #19 was always understood, always understands and was cognitively intact. Review of Resident #19's Trust Statements 09/10/2025 through 02/24/2026 revealed there were 20 documented transactions at the Country Store. 3. Resident #136 had diagnoses that included chronic obstructive pulmonary disease (COPD - a chronic lung condition), polyosteoarthritis (arthritis in many joints), and type 2 diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #136 was always understood, always understands and was cognitively intact. Review of Resident #136's Trust Statements dated 01/03/2024 through 02/16/2026 revealed there were 110 transactions at the Country Store. 4. Resident #138 had diagnoses that included hemiplegia and hemiparesis of left side, epilepsy (a brain disorder causing seizures), and type 2 diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #138 was understood, understands and was cognitively intact. Review of Resident #138's Trust Statements dated 01/04/2024 through 12/29/2025 revealed there were 105 documented transactions at the Country Store. 5. Resident #164 had diagnoses that included rheumatoid arthritis, epilepsy, and major depressive disorder. The Minimum Data Set, dated [DATE] documented Resident #164 was understood, understands and was cognitively intact. Review of Resident #164's Trust Statements dated 03/11/2024 through 02/24/2026 revealed there were 94 documented transactions at the Country Store. 6. Resident #167 had diagnoses that included paranoid schizophrenia, Alzheimer's Disease and dementia. The Minimum Data Set, dated [DATE] documented Resident #167 was understood, understands and was severely cognitively impaired. Review of Resident #167's Trust Statements dated 10/07/2025 through 12/31/2025 revealed there were nine (9) documented transactions at the Country Store. On 03/26/2026 at 10:40 AM The Administrator provided the following documents: - A copy of the letter that was sent out to Residents and Responsible Parties dated 02/23/2026 the letter documented that a comprehensive internal review of the accounting records related to the resident trust was conducted. It was discovered that there were inconsistencies in how Country Store transactions were recorded. Country Store spending activity dating back to 01/01/2024 would be reimbursed. -A document that stated quarterly statements were generated in 2024 and 2025. The document lacked evidence the quarterly statements were given or sent to Residents and/or their Responsible Parties. -A typed document that stated: Statements mailed on 02/26/2026 and Statements Hand delivered. There was a list of 29 residents on the document. Resident #18 was not listed on the document. An undated document titled Country Store Investigation the following was documented: -Family member of Resident #167 inquired about purchases related to the Country Store. Administrator reviewed the purchases and was unable to find documentation related to Country Store. -Business Office Manager #1 stated they did not have receipts for the transactions. They acknowledged that they should have the receipts. On 03/27/2026 The Administrator provided a document titled Meeting Minutes from The Chief Human Resource Officer. The document included an interview with Business Office Manager #1 that occurred on 02/19/2026. Business Office Manager #1 had stated to the Chief Human Resource Officer and Regional [NAME] President that they had no independent records (receipts) from the Country Store in terms of money in/out or transactions. On 03/27/2026 the Regional [NAME] President provided a document titled Summary of Interview with Business Office Manager #1 on 02/19/2026 with The Chief Human Resource Officer. It was documented that Business Office Manager #1 stated they did not keep a receipt book or activities order slips (receipt). Business Office Manager #1 acknowledged that there was no way to verify previous purchases and should have kept receipts or activity order slips to verify purchases but did not and was unable to provide proof of purchase. During a telephone interview on 03/23/2026 at 9:47 AM, the Ombudsman stated residents with personal funds accounts had recently received a letter from the facility regarding an audit that had occurred going back from January 2024 until current. The letter stated that residents were reimbursed for any store purchases, and the record keeping was not up to par. They stated that families were concerned because that was when they found out that residents were withdrawing $80 per week. Resident #18's representative was one of the concerned family members and questioned why they did not receive a quarterly statement. They stated that if they had received quarterly statements, this would have been caught a lot sooner. During an interview on 03/23/2026 at 10:16 AM, Resident #164 stated they did not receive any personal funds statements and wished they could get them. During an interview on 03/23/2026 at 10:53 AM, Resident #19 stated they had gotten a letter and were given money back. They were not sure what it was about or why they were getting money back. During a telephone interview on 03/24/2026 at 9:30 AM Resident #18's Responsible Party stated Resident #18 was refunded $2300 recently because of an audit that had occurred. They had received the letter and was refunded money, which was fine, but the fact that the facility had to audit from January 2024 through February 2026 was concerning. They stated that they were not receiving any quarterly statements and if they did, they would have caught the weekly charges and questioned them sooner. During an interview on 03/24/2026 at 10:10 AM, Resident #138 stated their only concern with the facility was when they got a letter about their personal funds account and received $1300 from the facility. During an interview on 03/26/2026 at 9:09 AM, Business Office Manager #2 stated that whenever funds were withdrawn from a resident's account a receipt was completed and filed. They stated quarterly statements were given to either Residents or their Responsible Party based on their BIMS (Brief Interview for Mental Status -a brief screen that aids in detecting cognitive impairment). They stated based on their experience; they would document whenever the quarterly statement was sent out in the private collections tab of the electronic medical record. Business Office Manager #2 stated they were unaware of the previous Business Office Manager #1's system; if any quarterly statements were sent, or if anything was documented as they had just recently started in this position. During an interview on 03/26/2026 at 10:40 AM, the Administrator stated they were unable to tell if quarterly statements went out because Business Office Manager #1 did not have good record keeping. On 03/26/2026 at 1:01 PM a call was placed to Business Office Manager #1. The voicemail box was not set up. Business Office Manager #1 did not return the phone call. During an interview on 03/26/2026 at 1:04 PM, the Administrator stated Business Office Manager #1 did not keep receipts and they were putting in transactions without having receipts from the Country Store. They stated Business Office Manager #1 was recording the transactions based on memory of what the residents had purchased. They stated receipts should have been kept verifying how much each resident had spent and to verify that the money was spent at the Country Store. During a telephone interview on 03/27/2026 at 8:53 AM, Resident #167's Responsible Party stated they originally were at the facility discussing concerns with Social Worker #1 and Medicaid Coordinator. During that discussion the Medicaid Coordinator made a comment about Resident #167 spending money weekly at the Country Store. Resident #167's Responsible Party stated they were shocked to hear that because Resident #167 had a diagnosis of dementia and would have bought anything that staff had offered to sell them. They stated Resident #167 was supposed to receive only $50 a month but was spending somewhere between $10-$25 a week at the Country Store. Something was wrong with the facility's record keeping. Resident #167's Responsible Party stated they were not receiving quarterly statements before 02/26/2026 and if they had received the quarterly statements, they would have caught this sooner. They stated they were questioning what Resident #167 was buying or if someone was taking advantage of Resident #167's mental state. During an interview on 03/27/2026 at 10:34 AM, the Medicaid Coordinator stated Resident #167's Responsible Party had come into the facility, Business Office Manager #1 was either not there that day or was unavailable, so they were reviewing how much money was in Resident#167's personal funds account with the Responsible Party. The Medicaid Coordinator stated they noticed the transactions for the Country Store and had mentioned them to Resident #167's Responsible Party. They stated Resident #167's Responsible Party had questioned what the transactions at the Country Store were for. There was a discussion on what Resident #167 could have been spending their money on. The Medicaid Coordinator stated the amount Resident #167 was spending weekly was a Red Flag to them. They stated, for example, seeing higher transactions like $28.50 on a weekly basis was a red flag to them because items at the Country Store were a low price. They stated the larger amounts coming out weekly just did not make any sense. They stated this had happened sometime in February, around the week of the 9-13th. They stated it would have been Business Office Manager #1's responsibility to document receipts and when quarterly statements were sent out. They stated that they were unaware of any statements that would have been sent out or any receipts. The Medicaid Coordinator stated that whenever Business Office Manager #1 was out of the office, they would assist Residents and Responsible Parties with telling them how much was in the personal funds account and if they wanted to make a deposit or withdraw money. They stated they did not assist with the personal funds' accounts in any other way. During an interview on 03/27/2026 at 10:45 AM, Social Worker #1 stated Resident #167's Responsible Party had concerns and at one point they were discussing items that were being purchased at the Country Store. The purchases were all the same amount and consistently made. Social Worker #1 stated they went to pull the sheet to see what Resident #167 was ordering from the Country Store, but they could not find any ordering sheets or receipts. They stated there were no receipts or accountability for the purchases that were made. Social Worker #1 stated they found out with the Medicaid Coordinator that there were more residents with consistent purchase amounts and frequency. They stated the list of resident names with these purchases all looked very interesting because the residents all had lower BIMS (Brief Interview for Mental Status) scores, ranging from moderate to severe cognitive impairment and the families were not invested as much with these particular resident's care. Social Worker #1 stated if there were receipts to back up the purchases, then it would have made sense but there were none. Social Worker #1 stated that it all looked very suspicious and there could have been some sort of financial abuse happening. After they noticed this, they had brought this to the attention of the Administrator on 02/11/2026. During an interview on 03/27/2026 at 12:10 PM, the Administrator stated Resident #167's Responsible Party questioned charges from the Country Store on 02/10/2026. They stated they began looking into the process for residents purchasing items from the Country Store and that was when they discovered the process was very sloppy. Business Office Manager #1 should have been keeping receipts of what was purchased at the Country Store to prove what the residents were buying and for proper bookkeeping. The Administrator stated Business Office Manager #1 should have sent out quarterly statements to Residents and their Responsible Parties so that they would have been aware of how much money was being spent and what it was being spent on. During an interview on 03/27/2026 at 12:24 PM, the Regional [NAME] President stated during the investigation of the Country Store, it was clear there was a lack of documentation and Business Office Manager #1 was not keeping receipts. Without the receipts it was hard to go back and figure out the transactions that had occurred. 10 New York Codes Rules Regulations 415.26(h)(5)(ii)(c)

Based on observations, interviews, and record review conducted during the survey the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #7) of one (1) resident reviewed for non-pressure related skin concerns. Specifically, staff did not report, assess, and monitor a skin injury on the resident's right shin. The findings are:The policy and procedure titled Skin Observation dated 06/29/2019 documented to report findings of assessment to the unit manager/supervisor. The unit manager/supervisor will initiate and complete a weekly nursing status documentation. The unit manager/ supervisor will notify the provider and obtain orders for appropriate treatment. Resident #7 had diagnoses of diabetes mellitus, hemiplegia (paralysis that affects one side of the body) affecting the left side, and a history of transient ischemic attack (a temporary blockage of blood flow to the brain). The Minimum Data Set, dated [DATE] documented that the resident was cognitively intact, able to understand others and be understood by others.The comprehensive care plan dated 02/07/2026 documented Resident #7 was at a risk for impaired skin integrity related to diabetes, and vascular ulcers bilateral lower extremities. Interventions included to check skin and feet with daily care and to document weekly on shower day. Resident #7 was at risk for skin injury related to anticoagulant therapy (blood thinner) interventions included to monitor skin for changes daily during care, administer treatment per physician orders, monitor and report any concerns. The Kardex (a guide for staff to provide care) dated 03/25/2026 documented to provide skin and feet checks with daily care and document weekly on shower day. Safety interventions included but not limited to monitor skin for changes daily during care and report. During an observation and interview on 03/23/2026 at 11:42 AM, Resident #7 was observed with edema (swelling), ecchymosis (bruising), and a skin injury on their right shin measuring approximately one (1) inch long and 1/2 inch wide. The resident stated they were on anticoagulants and had scraped their leg on the bed frame. During an interview on 03/25/2026 at 11:34 AM, Resident #7 stared they did not report the injury because it had stopped bleeding and that no staff had asked or assessed their shin. During an interview on 03/27/2026 at 11:02 AM, Certified Nursing Aide #1 stated they noticed the right shin injury and it was scabbed over when they showered Resident #7 the prior day. They stated they did not report it. They stated it was important to report skin issues because the injury could have reopened and caused an infection. They stated they were responsible for completing skin checks during showers and should have notified the nurse so the nurse could do an assessment. During an interview on 03/26/2026 at 4:18 PM, Licensed Practical Nurse #1 stated they had not been notified of Resident #7's skin injury to their shin. They stated staff should have immediately reported the injury so that a skin assessment, provider notification, and investigation could be initiated. They stated they expected all certified nursing aides to report all skin issues, especially for residents who received anticoagulants.During an interview on 03/27/2026 at 11:22 AM, the Director of Nursing stated certified nurse aides were trained to notify the nurse whenever they observed a skin issue so the nurse could complete a skin assessment. They stated skin checks should be completed daily during morning care and on shower days. 10 New York Code Rules Regulations 415.12(g)

Based on observations, interviews, and record review conducted during the survey the facility failed to ensure routine inspection, maintenance, and safe functioning of bed frames and mattresses was conducted as part of a regular maintenance program for one (1) (Resident #7) of one (1) resident reviewed. Specifically, Resident #7's bed frame lacked mattress retainers (bars that hold the mattress in place) according to the manufacture's specifications. In addition, routine inspections of beds had not been conducted since 2023.The findings are: The policy and procedure titled Maintenance, module management of environment of care maintenance dated 10/2024 documented the facilities maintenance department is responsible for all equipment and furnishings of the facility are repaired as needed by the maintenance department. Beds, bedtables, headboards, chairs and dressers are maintained in good condition. Resident related medical equipment will be inspected as per manufactures policy, along with preventative maintenance scheduled based on manufacturers' recommendations. Review of an operation and maintenance manual for (formal name of bed) Long Term Care Bed with a dated of 01/09/2017 documented proper patient assessment and monitoring, along with proper maintenance and use of the hospital bed system is required to reduce the risk of entrapment. The term hospital bed system encompasses the bed frame and its components, including the mattress, side rails, head and footboards and accessories to the bed. Inspect the bed for damage and normal operation periodically. Report any damage or abnormal operation immediately by the maintenance department. Mattress retainers FCEMAXX22 (bars that hold the mattress in place) were included with bed and instructed to ensure that the tension knobs under the headboard/footboard mounting brackets were tightened and that the space between the headboard and mattress and footboard and mattress were not to exceed 1 inch. A review of the facility's Resident Entrapment Assessment binder showed that routine bed assessments documented were through June 2023, with no evidence of ongoing audits or follow up. Resident #7 had diagnoses of diabetes, hemiplegia (paralysis that affects only one side of the body) affecting left side, and a history of transient ischemia accident (a temporary blockage of blood to the brain). The Minimum Data Set (a resident assessment tool) dated 02/07/2026 documented Resident #7 was cognitively intact. During an observation and interview on 03/23/2026 at 11:42 AM the mattress was too small for the bed. There was six inches of exposed metal frame along the outside parameter of the bed and there were not any bed mattress retainer bars noted (the metal foot bar that keeps the mattress from sliding). During an observation on 03/24/2026 at 9:18 AM Resident #7 was in bed and the mattress slid back, extended beyond the bed frame and not secured, leaving the metal frame exposed six inches. During an observation of Resident #7's bed on 03/26/2026 at 4:15 PM the mattress was observed pushed against the wall exposing six inches of the metal frame along the outside parameter of the bed, there were no mattress retainers to keep the mattress in place per the manufactures specifications. During an interview on 03/25/2026 at 11:34 AM Resident #7 stated the mattress never stays in place. During an interview and observation on 03/26/2026 at 4:18 PM, Licensed Practical Nurse #1 stated they had not been notified of Resident #7's unsafe bed condition. They stated staff should have immediately reported the mattress hazard so that a maintenance work order could have been initiated. Upon entering the room, Licensed Practical Nurse #1 confirmed the mattress did not fit the bed frame properly and was not secured. During an interview on 03/27/2026 at 11:02 AM, Certified Nursing Aide #1 stated they noticed the bed mattress slid off of the metal bed frame and thought maybe the mattress was too small for the frame. They stated they did not notify maintenance, but they should have said something, During an interview on 03/27/2026 at 11:22 AM, the Director of Nursing stated Certified Nursing Aide #1 should have notified the nurse about the mattress that slid off the frame, so the nurse could inform maintenance. During an interview on 03/27/2026 at 1:30 PM, the Director of Maintenance stated staff typically submit work orders when there was an issue with a resident's bed but acknowledged that bed audits had not been completed since June 2023, despite the expectation for routine checks. They stated they did have plans to re- implement bed audits routinely but have not as of yet. During an interview and observation on 03/27/2026 at 02:03 PM, Maintenance Staff #2 stated there was a lot of disorganization within the department and lack of familiarity with bed manuals or prior maintenance practices. They observed the bed frame and determined the mattress was not secure on the frame and stated they would address the issue right away. 10 New York Code Rules Regulations 415.29(b)

Based on observations, interviews, and record review conducted during a survey the facility failed to ensure that a resident with a suprapubic Foley catheter (a tube inserted directly into the bladder to drain urine) received appropriate treatment and services to prevent urinary tract infections for one (1) (Resident #10) of three (3) residents reviewed. Specifically, Resident #10's gravity drainage bag (used to collect urine) was not kept below the level of the resident's bladder.The findings are:The policy and procedure titled Catheter (Urinary & Suprapubic) Insertion and Removal last revised 08/2024 documented indwelling and intermittent catheters were utilized, when necessary, based on current professional standards of practice. The facility must ensure that the resident receives appropriate treatment and services to prevent urinary tract infections to the extent possible. To achieve a free flow of urine and maintain infection control, collecting bags were always kept below the level of the bladder.Resident #10 had diagnoses including urinary tract infection, retention of urine, and benign prostatic hyperplasia with lower urinary tract symptoms (enlargement of the prostate). The Minimum Data Set (a resident assessment tool) dated 02/05/2026 documented Resident #10 was cognitively intact, understands, was understood by others, and had an indwelling catheter.The comprehensive care plan dated 01/30/2026 documented Resident #10 was at risk for infection related to chronic kidney disease stage three (3) B (moderate to severe kidney function loss); had a suprapubic catheter related to neurogenic bladder (bladder with diminished sensation) with an intervention to follow recommended infection control precautions. Additionally, Resident #10 had a self-performance deficit related to Parkinsons disease (tremors of rigidity of movement) and required a maximal assist of one staff member for toileting (clothing management/hygiene).The Kardex (a guide used by staff to provide care) dated 03/26/2026 documented Resident #10 was on contact precautions (isolation precautions to prevent the spread of infection) for C- DIFF (Clostridium Difficile - bacteria in the bowel that may cause diarrhea).The Order Summary Report dated 03/26/2026 documented an order dated 03/18/2026 for a suprapubic catheter, change/irrigate catheter on as needed basis (plugged or dislodged).During an observation and interview on 03/26/2026 at 8:12 AM, Resident #10 was sitting up in their wheelchair, next to their bed. The foley catheter drainage bag was hanging on the left armrest of the wheelchair, above the level of the bladder. Resident #10 stated they did not realize the drainage bag was on the arm of the wheelchair. Resident #10 stated they were unable to move the drainage bag and place it underneath the chair; they would have asked staff to move the drainage bag if they had seen it.During an observation and interview on 03/26/2026 at 8:34 AM, Resident #10's foley drainage bag remained on their left arm rest. The collection bag was about 25 percent full of urine and was unable to drain to gravity. Certified Nurse Aide #4 stated they were responsible for Resident #10, and they had transferred Resident #10 to their wheelchair. Certified Nurse Aide #4 stated Resident #10 had hooked the foley drainage bag on the left armrest prior to the transfer, and they forgot to move it after the transfer. Certified Nurse Aide #4 stated the foley drainage bag should have been placed under the wheelchair so that urine could not flow back into the bladder; it was an infection control issue.During an interview on 03/26/2026 at 8:36 AM, Licensed Practical Nurse #3 stated foley drainage bags should always be placed below the level of the bladder; if the drainage bag was above the waist, urine could backflow into the bladder and cause infection. Licensed Practical Nurse #3 stated Certified Nurse Aide #4 was responsible for the appropriate placement of Resident #10's foley drainage bag after care was provided.During an interview on 03/26/2026 at 8:44 AM, Licensed Practical Nurse #4 Unit Manager stated Resident #10's foley drainage bag should not be hanging on their armrest, the drainage bag should always be below the level of the bladder, below the waist. They stated if the foley drainage bag was above the waist, urine could backflow and that was an infection control issue.During an interview on 03/26/2026 at 10:40 AM, the Educator/Infection Preventionist stated foley drainage bags should always be placed below the level of the bladder, that was what staff were taught and what was always expected. They stated it was important to avoid backflow; it opened areas for infection and with a suprapubic that could be severe. The Educator/Infection Preventionist stated Resident #10 had a suprapubic catheter, so it was especially important to ensure proper foley drainage bag placement.During an interview on 03/27/2026 at 9:49 AM, the Medical Director stated foley drainage bags should always be placed below the level of the bladder to promote drainage, if the foley drainage bag was not draining properly that could increase the risk for urinary tract infection and reflux. The Medical Director stated with Resident #10's history of urinary tract infections, it was important to ensure proper foley drainage bag placement and any staff caring for the resident was responsible for ensuring proper placement.10New York Code Rules Regulations 415.12(d)(1)

Based on interview and record review conducted during a Complaint investigation (#NY00339323) the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) met the needs of each resident. Specifically, for one (Resident #1) of three residents reviewed the facility did not ensure medications were acquired and administered in accordance with the physician's orders and professional standards. Resident #1 was not administered 20 doses of their antipsychotic medication. The finding is: The policy titled Ordering Medications/Treatments from Pharmacy, last revised 5/2023, documented medications and treatments would be obtained as prescribed by the prescribing practitioner for individual resident use. The policy titled Medication/Treatment Discrepancy/Error, last revised 3/2011, documented the purpose of the policy was to assure proper medication/treatment administration and compliance with the legal requirements of medication administration and to report all errors in medication administration and documentation. The attending Physicians shall be notified and the Consultant or Vendor Pharmacist and resulting orders carried out. A Medication Discrepancy/Error Report Form will be completed on all medication errors. 1. Resident #1 had diagnoses including Parkinson's disease (tremors and rigidity of movement), anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. The Minimum Data Set (a resident assessment tool) dated 1/24/24 documented Resident #1 was cognitively intact, understands, was usually understood, and received an antipsychotic. Review of comprehensive care plan dated 11/3/21 documented Resident #1 had history of falls and was known to intentionally place self on floor and crawl on their knees (2/24/23). The comprehensive care plan documented Resident #1 had history of periods of paranoid thoughts and expressions; seeing people/animals that aren't there; wandering into others' rooms, and an overnight mental health stay at hospital on 4/4/23. Interventions included to monitor therapeutic effects and side effects and report to provider as needed. The Psychiatry note dated 1/24/24 completed by the Neurologist/Psychiatrist documented Resident #1 was to start Nuplazid (antipsychotic medication used to treat hallucinations) 10 milligrams for continued behaviors of crawling on floor, refusing and fighting with staff when attempting to provide care. A nursing progress note dated 1/24/24 at 3:15 PM Licensed Practical Nurse Unit Manager #1 documented Resident #1 was seen by the Psychiatrist and had a new order for Nuplazid 10 milligrams once daily at bedtime. The note documented they were awaiting approval from the insurance company. On 1/31/24 at 4:32 PM it was documented the order for Nuplazid was approved for 14 days at a time. The Order Summary Report dated 3/4/25 documented a physician's order for Nuplazid 10 milligrams, give 1 tablet by mouth at bedtime time for 14 days starting on 1/31/24. The order was to be renewed and continued every 14 days. Review of the Medication Administration Records dated 1/1/24 to 5/31/24 revealed there was no order in place for the Nuplazid 10 milligrams from 3/28/24 to 4/11/24 and 4/26/24 to 4/31/24. The medication was not administered on those dates. Review of the 72 Hour Summary dated 3/28/24 to 4/11/24 revealed there was no documented evidence Resident #1's Nuplazid was reordered or administered. The facility was unable to provide the 72 Hour Summary for 4/26/24 to 4/31/24. A nursing progress note dated 4/11/24 at 2:52 PM completed by Licensed Practical Nurse Unit Manager #1 revealed Resident #1 was examined for their monthly physician visit, and it was noted that Nuplazid 10 milligrams daily was reordered to start every night. In a follow up note on 4/11/24 at 2:57 PM, they documented Nuplazid must be reordered every 14 days per insurance, reorder on 4/12/24. A Physician progress note dated 4/11/24, Physician #1 documented Resident #1's psychiatry consult from 3/6/24 was appreciated and recommendations followed. However, the patient's Nuplazid fell off after two weeks. Will resume. Review of Resident #1 chart dated 3/28/24 to 5/1/24 revealed there was no documented evidence that medication error reports were completed regarding the 20 missed doses of Nuplazid. During an interview on 3/4/25 at 1:26 PM, Licensed Practical Nurse Unit Manager #2 stated they were not aware they had to physically write a new order every 14 days for Resident #1's Nuplazid. They thought it was like all other medications where you just click the reorder button. In mid-April the physician noted the medication needed to be reordered, so they wrote a new order at that time. Resident #1 had some behaviors during that time where they were refusing their medications and hands on care and had some episodes of placing themselves on the floor. Licensed Practical Nurse Unit Manager #2 stated they then realized the medication was not administered for a couple days again at the end of April and put the order in on 5/1/24. At that time they stated a reminder was added to their calendar to ensure it did not happen again. Licensed Practical Nurse Unit Manager #2 stated Nuplazid was very important for Resident #1's health status. Someone taking an antipsychotic should never stop it abruptly. Any time there was a lapse in a medication being given, the physician should be notified. If the doctor would have been updated about the reorder not being done, then they could have reordered it, and the resident wouldn't have gone without it for that long of a period. During an interview on 3/4/25 at 2:02 PM, the Neurologist/Psychiatrist stated Nuplazid was an important medication for Resident #1, to maintain their current mental health status. Resident #1 became dysfunctional without the medication. Resident #1 should have received the medication as ordered, once a day. The Neurologist/Psychiatrist stated the facility should have followed their protocols and reordered the medication according to the order. During an interview on 3/4/25 at 2:16 PM, the Assistant Director of Nursing (interim Director of Nursing) stated Nuplazid was a specific medication that required a new prescription to be written and signed by the physician every 14 days and needed to be entered into the computer system each time. There was a period when they were between unit managers on Resident #1's unit and this incident occurred during that time frame. The Assistant Director of Nursing (interim Director of Nursing) stated the cart nurses were responsible for alerting the unit managers when the medication was running low so that a new order could be written. Nuplazid was ordered by the resident's Neurologist/Psychiatrist and should have been followed per their recommendations. When a resident had a missed dose of any medication the provider should be made aware, especially an antipsychotic. The resident should be assessed for any adverse effects. If anyone goes without their antipsychotic for any amount of time, there were risks to the resident. During an interview on 3/4/25 at 2:45 PM, Licensed Practical Nurse Unit Manager #1 (former UM) stated the insurance company would only allow 2 weeks' worth of Nuplazid at a time, and they had to keep reordering it before it would run out. If there was a lapse in receiving a medication, the facility would have to update the physician. During an interview on 3/4/25 at 2:49 AM, the Consultant Pharmacist stated when a person abruptly stops taking Nuplazid behaviors and hallucinations could emerge. Resident #1 should have received it as ordered. They stated they stated they do a monthly review of antipsychotics but do not have any sort of role in the process or monitoring of reordering medications. The review and ordering process was typically done by nursing. If it was an insurance issue the nursing staff should ensure they were reordering the medication according to the time frame provided by the insurance company to ensure there was an adequate supply available. During an interview on 3/5/25 at 9:45 AM, the Administrator stated there were no medication error reports completed for Resident #1. During an interview on 3/5/25 at 11:34 AM, the Medical Director stated Nuplazid was specific in decreasing Resident #1's hallucinations and was used to put their mind at ease. They would have expected the medication to be given as ordered and notified if the medication was not reordered or administered. It was the facilities responsibility to ensure residents were receiving their medications as ordered. 10NYRCC 415.18 (a)

Based on interviews and record review conducted during a Complaint Investigation (NY00339323) the facility did not ensure they consulted with the resident's physician when there was a need to alter treatment significantly for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the facility did not ensure they consulted with the resident's physician when a medication was not administered as ordered, resulting in 20 missed doses. The finding is: The policy titled Medication/Treatment Administration Documentation, last revised 6/24, documented when medications or treatments are not available for administration as ordered inform the Nursing Supervisor immediately, Emergency medication kit is used, and the medical provider is notified, and immediate medication delivery is requested. The policy titled Change in Resident's Condition, Medication/Treatment or status, last revised 2/2025, documented the resident and/or responsible party and the attending physician are promptly notified in changes of care and resident condition. Nursing services will notify the resident's physician when a need to alter treatment significantly (discontinue or changes to an existing treatment due to adverse consequences, or to commence a new form of treatment). Resident #1 had diagnoses including Parkinson's disease (tremors and rigidity of movement), anxiety disorder, and unspecified psychosis not due to a substance or known physiological condition. The Minimum Data Set (a resident assessment tool) dated 1/24/24 documented Resident #1 was cognitively intact, understands, was usually understood and received an antipsychotic. Review of comprehensive care plan dated 11/3/21 documented Resident #1 had history of falls with an intervention that resident is known to intentionally place self on floor and crawl on knees, added on 2/24/23. The comprehensive care plan documented Resident #1 had a history of periods of paranoid thoughts and expressions; seeing people/animals that weren't there; wandering into others' rooms, and an overnight mental health stay at hospital on 4/4/23. Interventions included to monitor therapeutic effects and side effects and report to the provider as needed. The nursing progress note dated 1/24/24 at 3:15 PM, Licensed Practical Nurse Unit Manager #1 documented Resident #1 was seen by Psychiatrist/Neurologist with new order to receive Nuplazid (antipsychotic medication) 10 milligrams once daily at bedtime. Awaiting approval (from insurance). In a follow up note dated 1/31/24 at 4:32 PM, they documented the order for Nuplazid was approved for 14 days at a time. Review of a Psychiatry note dated 1/24/24, Resident #'1s Neurologist/Psychiatrist documented the resident was to start Nuplazid 10 milligrams due to continued behaviors of crawling on the floor, refusing and fighting with staff when they attempted to provide care. Review of the Order Summary Report printed 3/4/25, revealed an order for Nuplazid 10 milligrams, give 1 tablet at bedtime for Parkinson's with a start date of 1/31/24. The medication was not ordered from 3/28/24 to 4/11/24 and 4/26/24 to 4/30/24. There were no directions to contact the medical provider to have the medication reordered every 14 days. Review of Medication Administration Records dated March 2024 - April 2024 documented that there was no order in place for Nuplazid 10 milligrams at bedtime from 3/28/24 to 4/11/24 and 4/26/24 to 4/30/24 and the medication was not administered on these dates. Review of the nursing progress notes dated 3/28/24 to 4/10/24 and 4/26/24 to 4/30/24 revealed the medical provider was not updated regarding Resident #1's missed medication doses or the need to reorder the medication (Nuplazid). Review of the Physician progress note dated 4/11/24, Physician #1 documented Resident #1 had a psychiatry consult on 3/6/24 and recommendations were followed. However, the resident's Nuplazid fell off after two weeks and would be resumed. Physician progress notes from 3/28/24 to 4/10/24 and 4/26/24 to 4/30/24 revealed no documentation the provider was updated regarding the need to reorder the Nuplazid or the missed medication doses. The nursing progress note dated 4/11/24 at 2:52 PM, Licensed Practical Nurse Unit Manager #2 documented Resident #1 had a monthly physician visit and Nuplazid 10 milligrams daily was reordered. A note dated 4/11/24 at 2:57 PM, they documented Nuplazid must be reordered every 14 days per insurance, reorder on 4/12/24. During an interview on 3/4/25 at 1:26 PM, Licensed Practical Nurse Unit Manager #2 stated there had been an issue with the reordering process for Resident #1's Nuplazid due to insurance only covering a 14-day supply at a time. Every 14 days there had to be a new prescription written and signed off by the physician. During this time frame, Resident #1 had increased behaviors of placing themselves on the floor, was refusing their medication and was aggressive towards staff. They stated at the beginning of May 2024 they realized they did not reorder Resident #1's Nuplazid and they went without it for a couple days. As soon as they realized the medication was not ordered, they contacted the doctor and had the order restarted. They stated they should have had a better system in place to remind them to call the provider as soon as the medication needed to be reordered. During an interview on 3/4/25 at 2:02 PM, Resident #1's Neurologist/Psychiatrist stated they ordered Resident #1 Nuplazid 10 milligrams daily and the resident should take it as ordered. Without the medication, Resident #1 became very dysfunctional and if taken properly could have prevented them from having increased behaviors leading to falls. They stated the facility should follow their protocols for updating their physician anytime there was a lapse in treatment. They would have expected to have been updated if the facility was unable to obtain the medication. During an interview on 3/4/25 at 2:16 PM, the Assistant Director of Nursing (interim Director of Nursing) stated Resident #1's Nuplazid was only able to be ordered every 14 days due to their insurance. Every 14 days a new prescription had to be entered and signed off by the physician. They stated the medication cart nurse was responsible for reordering medication and if they were unable to do so they should inform the unit manager. They stated at the end of March 2024 to the beginning of April 2024 they were in between unit managers for the unit and that is possibly how the medication fell off. They stated the physician should have been made aware as soon as the medication needed to be reordered so that it could be administered accordingly. The physician should have been updated on any missed doses of medications. The resident should be assessed for any adverse effects. If anyone goes without their antipsychotic for any amount of time, there were risks to the resident. During an interview on 3/4/25 at 2:45 PM, Licensed Practical Nurse Unit Manager #1 stated they were the unit manager in February and March of 2024. They stated they usually tried to reorder Resident #1's Nuplazid before the 14-day mark but could not recall times when it was ordered late. Resident #1 was on the medication because they hallucinated, had behaviors and would place themself on the floor. They stated that Resident #1 had only been on it a short time before they left as unit manager, but their behaviors improved in that time frame. They stated anytime there was a lapse in a resident receiving any medication that was ordered daily, the facility should update the physician. It was important to reorder medications, especially antipsychotics so that they could be administered as ordered. During an interview on 3/4/25 at 2:49 PM, the Consultant Pharmacist stated when a person abruptly stopped taking Nuplazid behaviors and hallucinations could emerge. They stated Nuplazid was an important medication for Resident #1, and they should've received it as ordered. They stated they do a monthly review of antipsychotics but nurses in the facility were responsible for monitoring any issues in the interim. During an interview on 3/5/25 at 11:34 AM, the Medical Director stated they expected to be updated immediately when a residents medication needed to be reordered and when there was a lapse in a resident's medication. It was the facility's responsibility to ensure residents received their medications as ordered. 10NYRCC 415.3(f)(2)(ii)(c)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00337078) the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 3 residents reviewed. Specifically, Resident #1 was left alone in the bathroom while attached to a sit to stand lift and had a fall that resulted in a bruise to the side of their head. The finding is: The policy and procedure titled, Accident/Incident Investigation and Prevention, revised on 6/2023, stated the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The policy and procedure titled Interdisciplinary Care Planning, revised on 4/15/2024, stated the comprehensive care plan and Kardex (guide used by staff to provide care) must always be current and accurately reflect the resident's status. The Care plan/Kardex must always be reviewed by staff prior to initiating resident care. Additionally, Care Plans are accessible in electronic format to any person involved in care of the resident. Direct care staff has easy accessibility on the touch screen should they require access to the comprehensive Care Plan. Resident #1 had diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness of one side of body) affecting right dominant side, malignant neoplasm (a fast-growing cancer) of the brain, and vascular dementia. The Minimum Data Set (a resident assessment tool) dated 2/15/24 documented Resident #1 was cognitively intact was understood and understands. The comprehensive care plan dated 8/16/21 documented Resident #1 was at risk for falls related to cognition, mobility, and right sided weakness. An intervention was added on 3/9/22 stating Resident #1 must be supervised by staff while on the toilet. Additionally, the comprehensive care plan had an intervention dated 10/4/22 that Resident #1 required a sit to stand lift with 2 persons assist for all transfers The current Kardex with a print date of 7/25/24 still reflected the safety interventions (that were in place at the time of the fall) to include the resident must be supervised by staff while on the toilet and required a sit to stand lift with 2 persons assist for all transfers. Review of ACTS Complaint/Incident Investigation Report dated 3/6/24 at 3:10 PM documented Resident #1 was found lying on the floor in their bathroom between the toilet and wall, had the sling from sit to stand lift around their waist, only attached on one side. Certified Nurse Aide #1's statement documented they entered the bathroom and found the resident lying on the floor in their urine, resident was alone in the bathroom upon entering. During a revie completed on 8/12/24 of Safe Patient Handling Standing Lift Skills Competency dated 3/13/24 documented Certified Nursing Assistant #1 was educated by Registered Nurse #1 on locking breaks and using a second assist during transfers. This education was provided to Certified Nursing Assistant #1 when a break in care plan was identified after Resident #1's fall. The Nurse Progress Note dated 3/6/24 at 6:45 PM, written by Registered Nurse #3, documented Resident #1 was complaining they were unable to move their right knee, and had pain in their right hip and knee. The doctor was notified, and Resident #1 was transported to the ER (emergency room ) for evaluation. The Hospital Discharge summary dated 3/6/24 at 10:12 PM documented Resident #1 was seen in the emergency room after a fall. Resident #1 was diagnosed and discharged with a subgaleal hematoma (an accumulation of blood within the layers of soft tissue of the head between the connective tissue and membrane tissue that covers the surface of the skull) and hip pain. During an interview on 7/25/24 at 10:08 AM, Licensed Practical Nurse #1 stated that on 3/6/24 a certified nursing aide came and got them because Resident #1 was found on the floor. Registered Nurse #1 was then called and came to assess the resident. During an interview on 7/25/24 at 10:48 AM, Certified Nursing Assistant #1 stated that on 3/6/24 they assisted Resident #1 onto the toilet using the sit to stand lift. They then handed the resident their call bell, closed the door and exited the resident's room. When they returned to answer the call bell, Resident #1's belt was unbuckled, and they were lying half on the floor. Certified Nursing Assistant #1 stated they were not aware that Resident #1 had a care plan intervention in place to be supervised while on the toilet at the time of the fall. Certified Nursing Assistant #1 stated they don't check care plans very often. They stated they we're re-educated on the incident by Registered Nurse #1 and were educated on how to properly use the sit to stand lift. During a telephone interview on 7/25/24 at 10:57 AM, Registered Nurse #2 stated they recalled the incident and assessed Resident #1 Resident #1 in the bathroom and then again once they were in bed. During an interview on 7/25/24 at 11:45 AM, Licensed Practical Nurse #2 (former Unit Manager) stated they were alerted to the resident falling and went down to assess the situation. They stated Registered Nurse #1 was already in the room, so they started the investigation. Licensed Practical Nurse #2 stated when a resident needs to be supervised that means the resident must be within eyesight of the staff. During an interview on 7/25/24 at 12:40 PM, Resident #1 stated they were put onto the toilet with the sit to stand lift and left there by themselves. They were attempting to grab a urinal that was on the railing and could not reach it. Resident #1 stated they then unhooked the belt on the lift and attempted to reach further causing them to fall off the toilet. Resident #1 stated they were able to grab the call bell and ring it. Two aides then came into the room and found them on the floor. During an interview on 7/25/24 at 1:59 PM, the Director of Nursing stated they would expect Certified Nursing Assistants to check the Kardex prior to providing care to a resident. They should be checking the Kardex's daily. The Director of Nursing stated supervision to them would be within eyesight or ear shot. The Director of Nursing stated that if there was a break in care plan there could be injury or possible death to a resident. The Director of Nursing stated that if a break in care plan was found, they would expect education to be provided to that staff member. During an interview on 7/26/24 at 9:49 AM, Registered Nurse #1 (Educator Inservice Coordinator) stated they expected certified nurse aides prior to read the care plan prior to providing care to a resident and if they don't know what they're doing, to ask for help. Registered Nurse #1 stated certified nurse aides were taught to check care plans daily though their expectation would be for the certified nurse aides to check the care plans at least once a week for any changes. Registered Nurse #1 stated it was important for staff to check the care plans regularly because it spells out how to provide care for that resident. If they were not checking them regularly then breaks in care plan could occur resulting in abuse, falls, accidents, and indents. Registered Nurse #1 stated Certified Nurse Aide #1 was educated on 3/13/24 for failure to lock breaks and not using a second assist for this incident, this was a break in Resident #1's care plan. 10NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/1/23, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming, personal and oral hygiene for one (Resident #166) of four residents reviewed. Specifically, a resident who was dependent on staff for hygiene with facial hair was not shaved or offered to be shaved after their shower. The finding is: The policy and procedure (P&P) titled Activities of Daily Living dated 11/2016 documented each resident will receive and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. 1. Resident #166 had diagnoses which included Alzheimer's disease (a type of dementia), depression, and weakness. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/17/23 documented the resident was rarely understood, rarely understands, and had severe cognitive impairment. Additionally, the MDS documented Resident #166 required maximal assistance of staff for hygiene. Review of the untitled comprehensive care plan (CCP) revised 10/23/23 documented Resident #166 had a personal hygiene self-care performance deficit related to Alzheimer's disease and required maximal assist for hygiene. Review of the Kardex Report (a guide for staff to provide care) dated 11/30/23 revealed Resident #166 required maximal assist for personal hygiene. Review of the Nursing Progress Notes dated 11/1/23-11/30/23 revealed no evidence that Resident #166 refused ADL care, including shaving. Review of the Documentation Survey Report dated 11/1/23-11/30/23 documented Resident #166 refused care twice during the 7-3 shift for the month of November. During an observation on 11/27/23 at 9:47 AM, Resident #166 had multiple hairs on their chin approximately 0.25(inch) and longer. During an observation on 11/29/23 at 11:12 AM, Resident #166 had multiple black and white hairs on their chin approximately 0.5 long and many hairs on their upper lip approximately 0.25 long. During an observation on 11/30/23 at 8:13 AM, Certified Nurse Aide (CNA) #1 ambulated Resident #166 to the shower room. Resident #166 tried to leave the shower room soon after CNA #1 brought them to the room. CNA #1 opened the door for the shower room, ambulated Resident #166 into the hallway, and stated they were going to get Licensed Practical Nurse (LPN) #4 Unit Manager to help. Both CNA #1 and LPN #4 redirected Resident #166 back to the shower room and were able to complete the shower. Upon completion of the shower, CNA #1 dressed Resident #166 and LPN #4 assisted Resident #166 back to their room. LPN #4 assisted Resident #166 with brushing their hair. CNA #1 and LPN #4 offered deodorant and oral care to Resident #166. Resident #166 stated no and began to walk out of their room. Neither CNA #1 nor LPN #4 offered or attempted to shave Resident #166 during morning care. During an interview on 11/30/23 at 8:41 AM, CNA #1 stated they had completed care with Resident #166. CNA #1 stated if Resident #166 did not attempt to leave the room, they would have attempted to apply deodorant and provide oral care. CNA #1 stated they could not think of anything else that was needed to complete care. CNA #1 stated Resident #166 had a few whiskers and they should have attempted to shave them. CNA #1 stated shaving could have been part of Resident #166's routine prior to admitting to the facility, which would have made it important to the resident. CNA #1 stated Resident #166 was dependent on the staff for assistance both cognitively and for shaving. CNA #1 stated they were used to working with alert and oriented residents on another unit and that was why they did not think to attempt to shave the resident. During an interview on 11/30/23 at 8:43 AM, LPN #4 stated shaving was part of morning care. LPN #4 stated Resident #166 was not familiar with CNA #1 and that was probably why Resident #166 was more tough to provide care. LPN #4 stated the whiskers growing on Resident #166's chin could have been a dignity issue. LPN #4 stated, as the unit manager, ultimately, they were responsible to make sure the CNAs were providing care to the residents. LPN #4 stated they thought Resident #166 might have pushed a razor away if they saw it, but shaving should have still been attempted. During an interview on 12/1/23 at 10:20 AM, the Director of Nursing (DON) stated part of morning care was to shave residents if they wanted to be shaved. The DON stated it was expected for staff to reapproach the resident if they refused care. The DON stated when a CNA floats from one unit to the memory care unit, they were expected to anticipate all needs of the memory care residents, including shaving. The DON stated, many of the memory care residents were unable to tell the staff what they want and do not want and that was why their needs needed to be anticipated by staff. The DON stated the only policy they had regarding shaving and morning care was the ADL policy. 10 NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/1/23, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for two (Resident #192 and #31) of seven reviewed for quality of care. Specifically, there was lack of wound assessments for Resident #192 and #31 and #192 lacked a care of plan revision to accurately reflect the resident's status. The findings are: The policy and procedure (P&P) titled, Documentation of Pressure Ulcer and Chronic Wounds revision date 6/23 documented pressure ulcers and chronic wounds are monitored closely to monitor effectiveness of treatment and change in risk factors. Pressure, stasis and/or chronic wounds will be monitored daily (with documentation, when a complication or change is identified) which should include observations of the area if no dressing present or status of the dressing, signs/symptoms of possible complications and whether pain, if present, is adequately controlled. The P&P titled, Interdisciplinary Care Planning revision date 2/10/2023 documented a comprehensive resident-centered Care Plan is developed by the Interdisciplinary Team (IDT) upon admission and reviewed/updated on a regular basis throughout the resident's length of stay. The comprehensive Care Plan and Kardex (guide used by staff to provide care) must always be current and accurately reflect the resident's status. 1. Resident #192 had diagnoses including unspecified dementia, unspecified nondisplaced fracture of sixth cervical vertebra, and type 2 diabetes mellitus. The Minimum Data Set (MDS-a resident assessment tool) dated 9/29/23 documented Resident #192 had moderate cognitive impairment and was at risk for developing pressure injury (PI)/ ulcer (PU). Additionally, Resident #192 had a stage 2 (partial-thickness skin loss with exposed dermis) PU and a MASD (moisture associated skin damage) present upon admission. The comprehensive care plan (CCP) initiated 9/22/23 documented Resident #192 was at risk for impaired skin integrity related to (r/t) impaired skin integrity r/t dementia, diabetes, impaired mobility, pressure ulcer to the left buttocks, recent hospital stays and 11/18/23 right heel blister. The CCP was not revised to include Resident #192 had a left heel DTI (deep tissue injury). Review of Weekly Skin Tracking Sheet provided by Registered Nurse (RN) #1 Unit Manager, dated March 3, 2023, documented Resident #194 had a stage 2 PU, clear blister right heel, with an onset date of 11/18/23. The PU measured 3.5 x 4.5. The tracking sheet did not include the units of measure (inches (in), centimeters (cm)). Review of facility progress note dated 11/18/23 at 3:43 PM, LPN #7 documented Resident #192 had a soft boggy blister to their right heel and the nursing supervisor was aware. Additional review revealed progress notes dated 11/19/23 - 11/30/23 did not document any skin concerns to the resident's left heel. Review of Weekly Skin Status Documentation effective 11/23/23 the RN Unit Manager #1 documented Resident #192 had a Stage 2 to their left buttock that measured 0.3 x 0.2 x 0.1 centimeters (cm). There was no documentation regarding the right heel blister that included staging or measurements. Review of Wound Care Vascular Specialty Group note dated 11/23/23 documented Resident #192 had one stage 2 pressure wound to their left buttock and included measurements. There was no documented evidence the right heel was assessed and measured. During an interview on 11/27/23 at 1:42 PM, Resident #192 stated they had a sore on their buttock, and a blister or something on their heel. Resident #192 stated they had discomfort to their butt if they sat to long and that their heels throb at night. Additionally, Resident #192 stated staff were aware. The PT (physical therapy) daily treatment note documented on 11/28/23 Resident #192 reported pain in left heel, nursing notified. The Order Recap Report order dates 11/20/23-11/29/23, documented skin prep wipes (protective barrier), apply to right heel topically twice a day (BID) for blister. Order dates 11/29/23-11/30/23, documented skin prep wipes, apply to right and left topically BID for skin break down prevention. There was no location documented. Additionally, active order dated 11/30/23 documented skin prep wipes, apply to right and left heels topically BID for skin break down prevention. The Treatment Administration Record (TAR) documented Resident #192 had a weekly skin check completed by RN #1, unit manager on 11/29/23. Skin prep wipes ordered 11/29/23 at 7:00 AM was signed as completed by RN #1, Unit Manager on 11/29/29, morning (AM). During an observation on 11/30/23 at 8:04 AM, LPN #6 completed scheduled treatment to Resident #192's heels. Left lateral heel was noted with a dime size, deep purple area flush to surrounding reddened skin. The right heel was noted to have a large fluid filled blister. During an interview on 11/30/23 at 8:38 AM, LPN #6 stated Resident #192's left heel had a discolored area. LPN #6 stated it needed to be evaluated by the wound team and brought to the Unit Managers attention. During an observation and interview on 11/30/23 at 9:29 AM, Nurse Practitioner (NP #1), Wound Consultant, evaluated Resident #192's skin and stated this is the first-time hearing about it (referring to the heels). Resident #192 complained of pain to both heels during the evaluation. NP #1 stated the resident had a DTI to the left lateral heel that measured 1.5 (cm) by(x) 1.7 cm and was boggy (soft), and intact fluid filled blister to the right lateral heel measuring 3.5 cm x 4.5 cm and was very tender. NP #1 stated the skin alterations to Resident #192's bilateral heels were related to pressure based on evidence-based practice. During an interview on 11/30/23 at 10:04 AM, Certified Nursing Assistant (CNA) #3 stated Resident #192 had skin concerns to both of their heels. CNA #3 stated there was a black circular area on left and was present Monday (11/27/23) morning. CNA #3 stated they reported left heel skin concern to the nurse that worked Monday. CNA #3 also stated Resident #192 utilized heel booties, but other staff may not know because they weren't on their care plan (Kardex). During an interview on 11/30/23 at 10:14 AM, Licensed Practical Nurse (LPN) #8 reviewed Resident #192's TAR's and stated they would not know Resident #192 had a PU because it was indicated for prevention. LPN #8 stated they weren't aware Resident #192 had any pressure ulcers but that it would be important to know, so they could monitor their plan of care. During an interview on 11/30/23 at 10:54 AM, RN #1 Unit Manager (UM) stated they observed Resident #192's heels last week and they were boggy, and no blisters observed. RN #1 UM stated skin prep was initiated to heels as a preventative treatment. RN #1 UM stated they weren't aware that Resident #192 had any complaints of pain to their heels. RN #1 UM stated Resident #192 was at risk for PU development due to age, fragile skin, poor circulation, and DM. RN #1 UM stated Resident #192 could develop PU's to their heels from not being off loaded, as heels were pressure points. Additionally, RN #1 UM stated they send an email to the DON (Director of Nursing), MD, and NP, about skin concerns and discuss them in morning meetings. RN #1 UM wasn't sure they sent an email related to Resident #192's boggy heels, because it was busy, and they were also a supervisor. During an interview on 12/1/23 at 10:24 AM, LPN #7 stated they weren't aware Resident #192 had a skin concern to their left heel, only a blister bubble, to their right heel. Additionally, LPN #7 stated Resident #192 received heel booties after the right heel blister was found a couple Saturdays ago. During an interview on 12/1/23 at 1:03 PM, the Director of Nursing (DON) stated as soon as any skin concern was noted they expected documentation by immediate supervisor on location, measurements, a description, MD notification, a treatment order and family notification. The DON stated it was their responsibility to oversee RN assessments, but they need to be aware of skin concerns to assess them. The DON stated they were notified today (12/1) of Resident #192's skin concerns. Additionally, DON stated once an intervention was implemented, they expected it to be reflected on the resident's care plan and Kardex as it was the primary communication on how staff take care of their residents. 2. Resident #31 had diagnoses that included heart failure, atrial fibrillation (irregular heart rate), chronic obstructive pulmonary disease (COPD). The MDS dated [DATE] documented Resident #31 had moderate cognitive impairments. Resident #31's comprehensive care plan (CCP) revised 11/27/23, documented risk for impaired skin integrity. Interventions included to administer treatment per MD order, monitor, and document progress. The progress notes dated 11/13/23, revealed LPN #1 documented Resident #31 had a fluid filled blister to their right great toe. The resident denied pain and the supervisor was notified. Physician's orders dated 11/1/23 to 11/30/23 documented an active order with a start date of 11/13/23 to apply iodine (antiseptic) to the fluid filled blister on Resident #31's right great toe every morning (AM). The Treatment Administration Record (TAR) dated from 11/14/23 to 11/30/23 documented iodine was applied to the fluid filled blister on resident #31's right great toe as ordered. Review of interdisciplinary progress notes, MD progress notes and weekly skin documentation sheets dated 11/11/23 - 11/30/23 revealed there was no documented evidence of skin assessments for Resident #31's right great toe to include measurements. During an observation on 11/27/2023 at 10:52 AM, Resident #31 was sitting on side of bed with their right foot resting on the base of tray table. There was a soiled dressing on the floor beneath the tray table base and the resident's right foot was reddened and there was an open area on their right great toe. During an observation and interview on 11/30/2023 at 9:23 AM, LPN #1 cleansed Resident #31's right great toe with normal saline and applied iodine. The resident's right great toe was noted to be dark red with an open area that measured 2.5 cm x 1.0 cm. At the time of the observation LPN #1 stated they noted the blister to the right great toe on 11/11/23, documented the concern in progress notes, and told the supervisor (who they believed may have been the LPN Unit Manager #10 but was not sure). LPN #1 stated they do not assess wounds and that a Registered Nurse (RN) was required to complete the assessment. During an interview on 11/30/23 at 11:29 AM, LPN #9 Unit Manager (UM) stated they were not aware Resident #31 had a blister to their right great toe, until this AM when they were notified by LPN #1. LPN #9 UM stated a Registered Nurse (RN) should have been notified to complete an assessment. During an interview on 11/30/23 at 4:06 PM, the acting Director of Nursing (DON) stated if a resident had an alteration in their skin, it should have been reported to the RN nursing supervisor, and an RN assessment should have been completed. The DON stated they became aware of the Resident #31's skin concerns (toes) on 11/29/23. The DON stated they reviewed the resident's medical record and stated there was no RN assessment to include measurements and would have expected it to be done and documented. During an interview on 12/1/23 at 8:07 AM, LPN #10 Unit Manager stated the skin team was emailed, they did not notify an RN of Resident #31's skin concerns (right great toe). LPN #10 Unit Manager stated they should have had the resident's toes assessed and measurements should have been taken. Review of an email provided by Director of Nursing dated 11/27/2023, revealed Licensed Practical Nurse (LPN) #10 Unit Manager sent an email to the Nurse Practitioner (skin team) that documented it was brought to their attention that Resident #31's right great toe looks awful, and the baby toe now had blistered area, they were weeping and quite red. 10 NYCRR 415.12

Based on observation, interview, and record review during the Standard survey completed on 12/01/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in all rooms and sleeping areas with fuel-burning appliances, and on-going preventative maintenance of carbon monoxide detectors. This affected three (Ground, First, and Second floors) of three resident use floors and one of one Basement. The findings are: According to the 2020 Fire Code of New York State, patient rooms in nursing homes are defined as sleeping units. In residential and commercial buildings that contain a fuel burning appliance, carbon monoxide detection shall be installed in all rooms, occupiable space, dwelling units, sleeping areas, and sleeping units that contain a fuel-burning appliance. Additionally, the 2020 Fire Code of New York State stated carbon monoxide detectors shall be maintained in good working order in accordance with Section 915 of this code, National Fire Protection Association (NFPA) 720 (Standard for the Installation of Carbon Monoxide Detection and Warning Equipment), and the manufacturer's instructions/recommendations. Review of the battery operated carbon monoxide alarm with silence feature manufacturer's user's manual documented, regular maintenance, to keep the carbon monoxide alarm in good working order: test it every week using the test/ silence button. Vacuum carbon monoxide alarm cover at least once a month using the soft brush attachment. Test carbon monoxide alarm again after vacuuming. 1a. Observations on 11/27/23 between 10:09 AM and 2:59 PM and on 11/28/23 between 8:20 AM and 2:52 PM revealed plug-in style carbon monoxide alarms with battery back-up were installed on the Ground, First, and Second floors and the Basement. Further observation during these dates and times revealed resident sleeping rooms were located on the Ground, First, and Second floors and fuel burning appliances were located on the Ground floor and the Basement. During an interview on 12/1/23 at 8:17 AM the Plant Operations Director stated the carbon monoxide detectors located on the Ground, First, and Second floors and the Basement were plug-in style carbon monoxide detectors with battery back-up. The Plant Operations Director further stated the plug-in style carbon monoxide detectors were tested monthly and batteries were changed annually. The Plant Operations Director also stated the facility had documentation for the monthly testing of the carbon monoxide detectors and the facility was not conducting any cleaning of the plug-in style carbon monoxide detectors. Review of carbon monoxide detector log sheets showed the building's carbon monoxide detectors were located on the Ground, First, and Second floors and the Basement, the detectors had been tested monthly from January through November of 2023 and the last time the detectors were tested was on 11/13/23. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on observation, interview, and record review conducted during the Standard Survey completed on 10/1/21, the facility did not have the evidence that all alleged violations of abuse, mistreatment and neglect were thoroughly investigated for one (Resident #138) of two residents reviewed. Specifically, the lack of investigation into facial bruising of unknown origin. The finding is: The policy and procedure (P&P) titled Incident Accident Reporting dated 6/21 documented it shall be the policy to distinguish between an accident and incident, but to nevertheless report and investigate both such events through formal, but distinctly different, reporting processes to rule out abuse, neglect, or mistreatment. All incidents are to be reported immediately to the Charge Nurse on duty and Nursing Supervisor will then be notified. For any incident/accident where abuse, neglect, mistreatment, is known or suspected, notify the Director of Nursing and Administrator immediately and begin investigation. The P&P titled Abuse Reporting and Facility Incident Reporting dated 7/17 documented all personnel promptly report any incident or suspected incident of abuse, mistreatment, neglect and injuries of an unknown source. 1. Resident #138 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/23/21 documented Resident #138 had moderately impaired cognition, was usually understood and usually understands. Section J documented Resident #138 had no falls since admission. The Comprehensive Care Plan, CCP dated 8/27/19 documented Resident #138 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Resident Matrix dated 9/27/21 documented Resident #138 had a fall. The Visual/Bedside Kardex Report (guide used by staff to provide care) dated 9/30/21 documented Resident #138 was known to place self onto the floor and scootch across the floor. On 9/27/21 at 9:35 AM Resident #138 was observed seated in the hallway in their wheelchair, the resident had a 2-inch purplish pink bruise under their left eye with a large 6-inch faded yellowish green area on their forehead above their left eye. During an interview at the time of the observation Resident #138 stated they did not recall what occurred. Review of the Unit 1A 24-hour Summary from 9/1/21 through 9/29/21 revealed there was no documented evidence that Resident #138 had facial bruising, a fall or injury. Review of the Nursing Progress Notes from 9/1/21 through 9/29/21 revealed there was no documented evidence Resident #138 had bruising under their left eye and forehead. Review of the Nursing Weekly Skin Observations from 9/7/21 through 9/28/21 for Resident #138 revealed there was no documented evidence of bruising to the resident's eye and forehead. Review of the Facility Accident/Incident Reports provided by the facility revealed there was no investigation into the bruising below Resident #138's left eye and their forehead. During an interview on 9/30/21 at 9:36 AM, Registered Nurse (RN) #1 Unit Manager stated accidents/incidents were to be reported to the Nursing Supervisor. The Nursing Supervisor was responsible for completing a thorough investigation and notifying the family and the physician. The RN Unit Manager stated they noticed the bruising under Resident #138's left eye and forehead 2 weeks ago. The color was faded and thought it appeared old and had been reported. RN #1 UM stated they never followed up to ensure an investigation was conducted. During an interview on 9/30/21 at 10:11 AM, Licensed Practical Nurse (LPN) #2 stated they reported the bruise under Resident #138's left eye and forehead to LPN #3, Nursing Supervisor on 9/18/21. LPN #2 stated the LPN #3 Nursing Supervisor was responsible for completing an investigation into the bruise. During a telephone interview on 9/30/21 at 10:31 AM, LPN #3 Nursing Supervisor stated LPN #2 had reported the bruising under Resident #138's left eye and forehead on 9/18/21. LPN #3 Nursing Supervisor stated that Resident #138 stated to them that they (the resident) dug their knuckles into their cheek, therefore, LPN #3 stated they (LPN#3) ruled out abuse and mistreatment. LPN #3 instructed LPN #2 to review the nursing progress notes to determine if the bruising had been documented, and to initiate an investigation. LPN #3 stated they should have followed up with LPN#2 to ensure an investigation was completed and that anyone could initiate an investigation. During interview on 10/1/21 at 12:29 PM, the Director of Nurses (DON) the stated the expectation of the nurse on the unit was to notify the Nursing Supervisor if a suspected injury occurred. The Nursing Supervisor was responsible to start an accident/incident investigation, notifying the physician, family, and implement any care plan changes if needed. The information should be passed along via the twenty-four-hour report and verbal communication to the next shift. The DON stated they were unaware Resident #138 had any facial bruising. LPN #3 should have assessed the data, would expect a full investigation if there was no known cause of the bruising. The purpose of the investigation was to refute that abuse occurred. LPN #3 should have had better communication as a Nursing Supervisor and would expect to have been notified by telephone of a bruise of unknown origin. 415.4 (b)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/1/21 the facility did not ensure that residents who use [CONDITION(S)] drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs. One (Resident #138) of five residents reviewed for unnecessary medication use was on [MEDICATION(S)] (anti-psychotic medication) without an adequate indication for continued use. In addition, there was no supporting documentation to justify an increased [MEDICATION(S)] dose on 9/21/21 and for continued use of the medication. The finding is: Review of a facility policy entitled [CONDITION(S)] Med Use Initiation and Gradual dose reduction dated 3/07 revealed residents were evaluated for the initiation/continued need for [CONDITION(S)] medications and the determination of whether he/she is being maintained on the lowest effective dose. The Unit Coordinator in concert with the Interdisciplinary Team IDT determines if a resident's behavior is of new onset or worsening and requires daily monitoring via Behavior Monitoring record. Non-pharmacological approaches are trialed prior to psychological medication initiation. The behavior monitoring record captures specific behavior categories, medication side effects, medication changes, and behavioral interventions. The Attending physician, social worker and the Unit Coordinator evaluates the continued need of psychopharmacological medication use and determine whether the resident is being maintained on the lowest effective dose. A determination is made based on evaluation of target symptoms, effect of medication, clinical stability and/or resolution of underlying causes. 1. Resident #138 had diagnoses which included Alzheimer's Disease, dementia with behavioral disturbance, and major depressive disorder (MDD). Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/23/21 revealed that the resident had moderately impaired cognition, was usually understood and usually understands. The MDS documented there were no potential indicators of [CONDITION(S)], no behavioral symptoms, no behaviors were exhibited during care and no wandering behavior was exhibited. The MDS also documented the resident received an antidepressant and antipsychotic medication on a routine basis. Review of the Comprehensive Care Plan (CCP) dated 6/30/20 revealed the resident was on [MEDICATION(S)] (antipsychotic) 50mg (milligrams), was weepy, cried often, and missed their family. Goals included the resident would continue to be free of mood and behavior problems through next review. Approaches included music therapy, opportunities for participation in song writing/song discussion, tele med psych services, behavioral counseling, and to listen to expression of feelings. Review of an undated Visual/Bedside Kardex Report (care guide used by staff to direct care) revealed re-direction and diversional activities for safety. Review of the Physician's Orders from 5/19/21 through 9/20/21 revealed [MEDICATION(S)] 25 mg one tablet by mouth at bedtime for dementia with behaviors. On 9/21/21 the Physician's Orders revealed a new order for [MEDICATION(S)] 50mg one tablet by mouth at bedtime for depression. In addition, there was an order for [MEDICATION(S)] (antidepressant) 200 mg by mouth daily for depression. Review of Medication Administration Records (MAR) from May 21, 2021 through September 20th, 2021 revealed the resident received [MEDICATION(S)] 25mg every day for dementia with behaviors. Further review of the MAR dated 9/21/21 through 9/29/21 revealed [MEDICATION(S)] 50mg one tablet by mouth was given at bedtime for depression. Intermittent observations made from 9/27/21 and 9/30/21 between 8:00 AM and 3:00 PM revealed Resident #138 was in the Unit 1A hallway asleep in a wheelchair. In addition, on 9/29/21 at 1:17 PM Resident #138 self-propelled in their wheelchair from the Unit 1A dining room to the hallway engaged in conversation with other residents and laughing. There were no weepy or aggressive behaviors observed. Review of the Behavior Flow Sheet/Psychoactive Drug Records from May 2021 through September 2021 revealed the following target behaviors: May 2021: weeping was noted 27 times and self-transfers was noted 15 times June 2021: weeping was noted 28 times July 2021: weeping was noted two times August 2021: weeping was noted two times September 2021: weeping was noted 12 times Review of the Physician Progress Notes revealed the following: 5/24/21- Alzheimer's dementia with behavioral disturbances. Stable; continue all current measures, Major depression characterized by anorexia, flattened affect, decreased intake and history of weight loss. Weight is stable. 6/28/21, 8/2/21, and 9/9/21 the notes documented the resident was stable and to continue all current measures. There was no documentation of resident behaviors or whether decreasing [CONDITION(S)] medication was clinically contraindicated. Review of the Behavioral Health Consults dated 5/28/21, 6/18/21,7/9/21, and 8/6/21 revealed the Licensed Certified Social Worker (LCSW) documented staff reported Resident #138 had been stable and reported no concerns. Review of the Nursing Progress Notes from 5/20/21 through 9/21/21 revealed the following notes regarding behaviors and non-pharmacological interventions that were provided: On 5/20/21 at 2:19 PM, increased yelling and weeping at times. 1:1 with no effect. On 5/20/21 at 9:58 PM, resident a little agitated at the beginning of the shift. On 5/22/21 at 2:58 PM, weepy this afternoon she didn't know what to do with herself. On 7/6/21 at 5:59 AM, weepy this shift, did not sleep at all. Resident wanted to go home and see their family. Resident self-transferred onto the floor and scooted themself out into the hallway. Resident redirected and put back to bed and then self-transferred several times. On 9/13/21 at 2:43 PM, increase in weeping, 1:1 with little effect. On 9/14/21 at 2:42 PM, cried on and off, 1:1 with some effect. On 9/16/21 at 1:39 PM, sad, always leaning on right arm, refused activities. On 9/20/21 at 2:43 PM, sad and wanted to go home, 1:1 with no effect. Review of a Nursing Progress Note dated 6/16/21 at 2:28PM revealed the resident was discussed during a Gradual Dose Reduction (GDR) meeting. Pharmacy recommended to discontinue (D/C) [MEDICATION(S)] 25mg. Resident 138's son was not in agreement to discontinue the [MEDICATION(S)]. There was no documentation the family was educated about side effects of [CONDITION(S)] medication or that a decrease in [CONDITION(S)] medications was clinically contraindicated. A Nursing Note dated 9/21/21 at 10:38 AM the Registered Nurse (RN) Unit Manager (UM) (RN #1) documented the Physician was notified Resident #138 had increased weeping and crying spells. [MEDICATION(S)] 25 mg was increased to [MEDICATION(S)] 50mg once daily. On 9/22/21 at 8:05 AM RN #1 UM further documented Resident #138 was discussed at the GDR meeting on 9/21/21 and family requested no changes to medications. Review of the Behavioral Health Consult dated 9/24/21 revealed the LCSW documented Resident #138 continued to be weepy most of the time. Services were no longer medically necessary and resident was not a good candidate for services due to memory loss and ability to recall what had been discussed. Behavioral visits were discontinued. Review of the Unit 1 A Order Listing Report (used by staff during GDR meetings) revealed the following for Resident #138: May 18th, 2021- On [MEDICATION(S)] 25 mg one tablet by mouth at bedtime for dementia with behaviors. Self-toileting and crying were listed as target behaviors. September 21, 2021- On [MEDICATION(S)] 50 mg one tablet by mouth at bedtime for depression. No target behaviors were identified and revealed no GDR per family request. During an interview on 9/29/21 at 1:06 PM, Certified Nurse Aide (CNA) #1 stated target behaviors for Resident #138 included weeping, wandering and self-transferred. During an interview on 9/29/21 at 1:29PM, CNA #2 stated Resident #138 would cry and want to go home. After distraction and redirection, the crying subsided. During an interview on 9/29/21 at 3:22PM, Licensed Practical Nurse (LPN) #1 stated Resident #138 looked for their spouse, occasionally was weepy. The LPN stated the behaviors were not a threat to the resident or others and when the resident was consoled and redirected, they were fine. During an interview on 9/30/21 at 9:36AM, Registered Nurse (RN) Unit Manager (UM) (RN #1) stated, CNA's reported resident behaviors to the LPN's. The LPNs documented target behaviors on the Behavior Flow Sheet/ Psychoactive Drug Record. After discussion with the Interdisciplinary Team (IDT), target behaviors for Resident #138 were determined as weeping and self-transfers. RN (UM) RN#1, stated Resident #138 was depressed, cried, and self-transferred. Non-Pharmacological interventions were behavior counseling, music therapy, and 1:1 interaction. RN UM (RN#1) stated they notified the Medical Director after the GDR meeting on 9/21/21 because Resident #138 had increased weeping. During a telephone interview on 10/1/21 at 8:53 AM, the Consultant Pharmacist stated the last GDR meeting was on 9/21/21. The IDT discussed Resident #138's uncontrolled crying related to depression therefore the RN UM (RN#1) notified the Medical Director of increased crying episodes. The Medical Director increased [MEDICATION(S)] 25mg to [MEDICATION(S)] 50mg one time daily by mouth for depression. The Consultant Pharmacist was unable to recall additional behaviors and stated the crying posed a risk to the resident or others within the environment and agreed with the increased [MEDICATION(S)] on 9/21/21. During an interview on 10/1/21 at 10:29AM, the Unit 1 A Social Worker stated Resident #138 felt their family had abandoned them and was mad at the world and cried unconsolably. Resident #138 would get up and down without assistance and was at high risk for falls. The Social Worker stated, the facility had used antipsychotics for residents who self-transferred. The Social Worker stated the [MEDICATION(S)] was used for Resident #138's inconsolable crying and depression. During a telephone interview on 10/1/21 at 10:56 AM, the LCSW stated Resident #138's mood had improved and was unable to participate in counseling due to impaired cognition. Therefore, Resident #138 was discharged from counseling services on 9/24/21. The LCSW was unaware of the increased [MEDICATION(S)] 50mg that was ordered by the Physician on 9/21/21. During an interview on 10/1/21 at 12:36 PM, the Director of Nurses (DON) in the presence of the Administrator and the Regional Vice President, stated Resident #138 had cried frequently and would have expected the nurses to document a well-rounded story of the occurrences, trends and behaviors that had escalated to support the use of the antipsychotic medication. The DON stated antipsychotics were indicated for a resident when a behavior imposed a negative impact to themselves or others. The DON stated Resident #138 could get paranoid and fearful, but nothing was reported recently. Weepiness, along with self-transferring were not appropriate target behaviors. During a telephone interview on 10/1/21 at 1:15 PM, the Medical Director stated antipsychotics were used for refractory depression. Resident #138 cried and had dark circles under their eyes. The antidepressant [MEDICATION(S)] was at the maximum dose achieved. RN UM (RN#1) called them (the Medical Director) on 9/21/21 and was informed of the resident's increased crying episodes. Typically, the Medical Director advised the nursing staff to contact psych services for residents on dual therapy. The facility had trouble reaching out to psych services and therefore decided to increase the [MEDICATION(S)] to 50mg. The Medical Director stated, we could have stopped the [MEDICATION(S)] or switched to a different therapy. The [MEDICATION(S)] was used to treat severe depression, not agitation. 415.12(1)(2)(ii)

Based on observation, interview, and record review completed during a Standard survey completed on 1/18/19, the facility must ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for two (Resident #15 and #181) of two residents reviewed for respiratory care. Specifically, both resident's oxygen (O2) concentrators had filters that were soiled with thick grey dusty debris and unlabeled, undated O2 tubing. The findings are: Review of the policy and procedure entitled Oxygen Equipment dated 1/1/15 revealed all oxygen equipment will be maintained on a monthly basis. A supply of replacement filters, tubing and batteries are kept in stock for the various brands of O2 concentrators. Filters are cleaned weekly and the tubing is changed every two weeks. 1. Resident #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 1/4/19 revealed the resident was sometimes understood, sometimes understands and was severely cognitively impaired. The MDS documented the resident required the use of oxygen therapy. The comprehensive care plan (CCP) last reviewed 10/17/18 documented the resident had impaired [MEDICAL CONDITION] function related to [MEDICAL CONDITION] with interventions that included oxygen per the physician's orders [REDACTED].>The undated Order Review Report documented an order to apply O2 via nasal cannula (NC) at two liters at bedtime (HS) when resident refuses [MEDICAL CONDITION] (Continuous Positive Airway Pressure, treatment that uses mild air pressure to keep your breathing airways open) machine and remove in the morning. Review of the Medication and Treatment Administration Records (MAR and TAR) dated (MONTH) (YEAR) and (MONTH) 2019 revealed an order entry to apply O2 via nasal cannula at two liters at HS when resident refuses [MEDICAL CONDITION] machine and remove in the morning. Further review of the TAR with an order date of 1/16/19 revealed to change O2 filter and change tubing weekly on Tuesdays on the night shift. There was no documented evidence on the (MONTH) TAR to change the O2 concentrator filters or change the tubing. Intermittent observations of Resident #15 from 1/15/19 to 1/18/19 revealed the following: - 1/15/19 at 6:54 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was labeled 1/14/19 and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/16/19 at 7:35 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was labeled and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/17/19 at 7:00 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was labeled and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/18/19 at 11:30 AM - Resident was out of bed and O2 was not in use. The filter on the left side of the oxygen concentrator was still covered with thick grey debris. 2. Resident #181 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was understood, understands and was moderately cognitively impaired. The MDS also documented the resident required the use of oxygen therapy. The comprehensive care plan (CCP) last reviewed 12/25/18 documented the resident [MEDICAL CONDITION] of the left upper lung. The undated Order Review Report documented an order to apply O2 at two liters via nasal cannula continuously. Review of the MAR and TAR dated (MONTH) (YEAR) and (MONTH) 2019 revealed order entry for O2 via nasal cannula at two liters continuously. Further review of the TAR with an order date of 1/16/19 reveal change O2 filter and change tubing weekly on Tuesdays on the night shift. There was no documented evidence on the (MONTH) TAR to change the O2 concentrator filters or change the tubing. Intermittent observations of Resident #181 from 1/14/19 to 1/18/19 revealed the following: - 1/14/19 at 2:10 PM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was not dated or labeled, and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/15/19 at 2:00 PM - Resident was in bed and the O2 tubing was labeled 1/15/18. The filter on left side of the oxygen concentrator was still covered with thick grey dusty debris - 1/16/19 at 2:08 PM - Resident was sitting up in a w/c (wheel chair) in their room and O2 was on at two liters via NC. The left side filter of the oxygen concentrator remained dusty with grey debris. - 1/17/19 at 9:59 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was not labeled, and left side filter was covered with thick grey debris. - 1/18/19 at 11:34 AM - Resident was in bed and O2 was at two liters via. The oxygen tubing was not labeled, and the left side filter of the oxygen concentrator was still covered with thick grey debris. During an interview on 1/16/19 at 2:17 PM, the Licensed Practical Nurse (LPN #1) stated the 11:00 PM to 7:00 AM shift changes the O2 tubing weekly, extension tubing would be changed monthly, and filters get cleaned by the 11:00 PM to 7:00 AM shift as well. There would be an order and it would be on the MAR/ TAR; any resident on O2 would have orders on the MAR/ TAR to change the tubing and clean the concentrator filters. During an interview on 1/16/19 at 2:26 PM, the Registered Nurse Unit Manager (RN UM #2) stated the LPNs on the 11:00 PM to 7:00 AM shift maintain the oxygen equipment; they change the tubing and clean the filters weekly. There should be orders and it would on the MAR/ TAR. If it's not on the MAR/ TAR they wouldn't know to change the tubing or clean the filters. During an interview on 1/17/19 at 7:12 AM, RN UM #2 stated she checked all the residents on the unit for orders to change the oxygen tubing and to clean the filters weekly. Only one out of the seven or eight residents had an order. She wasn't sure if it didn't get carried over when they switched to electronic medical records. 415.12(k)(6)

Based on interview and record review conducted during the Standard survey completed on 1/18/19, the facility did not ensure that written notification was sent to the resident, the resident's representative, and a representative from the Office of the State-Long Term Care (LTC) Ombudsman of the resident's transfer or discharge for two (Residents #145, 199) of two residents reviewed for admission, transfer, discharge notice requirements. Specifically, there was no documented evidence the resident, resident's representative, or ombudsman were notified in writing by the facility when the residents were transferred to a hospital from the facility. The findings are: The facility policy entitled Discharge Notice dated 1/1/15 documented when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable. Copies of the notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. 1. Resident #199 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) accepted into the database included Discharge Assessment Return Anticipated dated 12/11/18 and 12/20/18. Review of the nursing Progress Notes dated 12/11/18 revealed the resident was sent to the hospital and admitted for UTI (urinary tract infection) [MEDICAL CONDITION] (a severe blood infection). Additionally, a Progress Note dated 12/20/18 revealed the resident was sent to the hospital and admitted for UTI and leukocytosis (elevated white blood cell count). Review of the entire medical record revealed there was no documented evidence that discharge notices were provided to the resident, resident's representative, and a copy was sent to the Office of the State Long-Term Care Ombudsman as required. During an interview on 1/18/19 at 11:00 AM, the Discharge Planner stated she has not been giving the discharge notice to the residents who go to the hospital nor has she been letting the ombudsman's office know about it. The discharge planner stated it was just brought up recently that she should be doing it. During an interview on 1/18/19 at 12:15 PM, the Social Worker (SW) stated the Discharge Planner was supposed to have been giving the notices. A previous staff member was responsible for doing it but she no longer works at the facility. During a telephone interview on 1/18/19 at 12:40 PM, the ombudsman representative stated they have not been getting the notices of transfers or discharges from this facility. 2. Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 12/8/18 documented the resident had long and short-term memory problems, rarely understood by others, and rarely understands others. Review of the Minimum Data Set (MDS - a resident assessment tool) accepted into the database included Discharge Assessment Return Anticipated dated 10/28/18 and 11/1/18. Review of the entire medical record revealed there was no documented evidence that discharge notices were provided to the resident, resident's representative, and a copy was sent to the Office of the State Long-Term Care Ombudsman as required. Review of the nursing Progress Notes dated 10/28/18 at 12:55 AM revealed that the resident's J tube (a tube that is inserted into the small intestine for venting air or drainage or providing an alternate way for feeding) was leaking and the facility staff could not obtain an X-ray to determine the location of the tube. The resident left the facility at 1:25 AM and went to the emergency department at a local hospital. The hospital then transferred the resident to another hospital that was more familiar with her case. The resident returned to the facility on [DATE] at approximately 4:00 PM. A review of the Social Work Progress note dated 10/31/18 revealed that the resident was evaluated for an admission/ readmission by Social Work. A review of the nursing Progress Notes dated 11/1/18 revealed that the resident was to be sent to a medical center for scheduled surgery. The resident was discharged from the facility on 11/1/18 and was readmitted to the facility on [DATE]. A review of a Social Work Progress note dated 11/8/18 revealed that the resident was evaluated for an admission/ readmission by Social Work. During an interview on 1/18/19 at 12:13 PM, Social Worker (SW) #2 revealed that she oversaw the unit that the resident was on. She did not send out a discharge letter to the facility's Ombudsman or the Ombudsman's office. She also stated that the person who used to do the discharge letters no longer works at the facility. She stated they used to send a fax to the Ombudsman office at the end of the month for all that month's discharges. She stated that they have not sent out discharge letters since that person left. 415.3(h)(1)(iv)(d)

Based on interview and record review conducted during an Abbreviated Survey (Complaint #NY 605) completed on 9/18/17, it was determined that the facility did not report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within five working days of the incident. One (Resident #1) of four residents reviewed for accidents [MEDICAL CONDITION] three occasions while smoking and the incidents were not reported or not reported timely to the State Survey Agency. The finding is: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS - a resident assessment tool) dated 8/19/17 revealed the resident is understood, understands and is cognitively intact. Review of the current Care Plan Activity Report (comprehensive care plan) revealed a focus area for Smoking - Non Responsible Smoker was initiated 5/4/16. The Care Plan Activity Report documented that the resident was a former smoker; he resumed smoking after admission to the facility; and is often noncompliant with wearing a smoking apron. Review of the current Resident Nursing Instructions (certified nurse aide (CNA) care plan) printed 9/8/17 revealed the section for Safety implemented 4/28/17 documented that the resident was given a Wander Guard (device to detect wandering). An intervention dated 6/16/17 documented that the resident Must wear smoking apron and use smoking device when smoking- put in wheel chair bag. May not smoke without staff supervision three-five feet away. Wander guard on wheel chair. a.) Review of an Incident/Accident Report, completed by a Registered Nurse, dated 1/2/17 at 3:30 PM revealed Resident #1 was outside smoking without wearing a lap protector (smoking apron); the end of his cigarette fell on his leg; and he sustained a 1 cm (centimeter) round superficial blister on his right thigh. Review of physician's orders [REDACTED]. Review of a Nursing Progress Note dated 1/2/17 at 4:07 PM revealed Aide notified nurse that resident came back from smoking outside and had a 1 cm/ 2 cm burn on his upper thigh. Resident stated he didn't have the lap protector on. Family and Supervisor notified. Review of an Online Submission form dated 3/17/17 at 4:52 PM revealed the incident (burn) that occurred on 1/2/17 at 3:30 PM was reported to the New York State (NYS) Department of Health (DOH). b.) Review of an Incident/ Accident Report, signed by an RN and the Director of Nursing (DON), dated 3/25/17 at 2:45 PM revealed that the resident reported that ashes may have landed on his shirt, while he was smoking outside by the back door. The Report documented that the resident had a 1/2 cm area on the outer aspect of of the right forearm. The area was cleansed with normal saline and [MEDICATION NAME] (antibiotic ointment) was applied. A Nursing Progress Note dated 3/25/17 at 11:06 PM documented that as 3:00 PM-11:00 PM staff were entering the building, Resident #1 was sitting outside near the back-door smoking. The resident asked the staff to look at his shirt because he thought smoke ashes may have landed on his shirt. The Progress Note documented that the resident had a ½ cm round area on the outer aspect of the right lower arm and there was a burn hole on his jacket. Review of information provided by the facility regarding the Incident/Accident that occurred on 3/25/17 revealed no documented evidence that the incident was reported to the NYS DOH. c.) Review of an Incident and Accident Investigation Report dated 3/27/17 at 8:30 PM revealed the resident stated he burned his chest with a cigarette and he sustained a 0.3 x 0.3 blister. The Report documented that the resident was out on pass, without his smoking vest. Review of a Nursing Progress Note dated 3/29/17 revealed documentation related to Accident/Incident IDT (Interdisciplinary Team) Conclusion of 8:30 PM 3/27/17. The Progress Note documented that the Resident was outside with another resident smoking and burned self from ashes; burn to sternum. The skin is [DIAGNOSES REDACTED]tous (reddened) and not broken. Review of information provided by the facility for the Incident/Accident that occurred on 3/27/17 revealed no documented evidence that the incident was reported to the NYS DOH. During an interview on 9/8/17 at 11:20 AM, the resident stated he did burn himself with a cigarette when he was out on pass with a friend. He stated he went to flick the cigarette out of his mouth and it bounced off the ashtray onto his shirt in a folded area. His friend attempted to look for it but could not find it. When he returned to the facility that night, it was his CNA (certified nurse aide) who found it in his shirt. The resident said he had a blister in the area where the cigarette was located. He stated that he has several burn marks from cigarettes. During an interview on 9/15/17 at 10:07 AM, the DON stated I don't know what happened to the accident report I filed with the state for the 1/2/17 incident. I did file it right away but apparently, it didn't go through. I thought I had submitted it in January (2017) when the incident occurred and found out later it never went through. I did not get a confirmation number because I didn't know I needed one. We found out that it wasn't submitted through a mock survey done here at the facility. I then resubmitted on 3/17/17 and this time received a confirmation number. The other two incidents on 3/25/17 and 3/27/17 were not submitted because the skin was not broken. I discussed both with the administration team and we felt it did not need to be reported. During a telephone interview on 9/18/17 at 3:30 PM, the Administrator stated the incident on 1/2/17 was reported to the DOH, but the DON never received the confirmation number. The incidents that happened on 3/25/17 and 3/27/17 were before the new incident manual came out. I believe the old manual doesn't state that [MEDICAL CONDITION] to be reported. Review of the current NYS DOH Nursing Home Incident Reporting manual dated 8/2016 revealed At least one of the following elements must be present for an incident to be reportable to the NYS DOH: Accident resulting in a burn to the body surface. Review of a facility policy and procedure (P&P) entitled Abuse Reporting and Facility Incident Reporting dated 7/2017 revealed any alleged violations involving mistreatment, neglect or abuse, including injuries of an unknown source, misappropriation of resident property, and exploitation will be reported to the appropriate involved parties and state agencies. The P&P documented One of the following elements is needed for report to the DOH (Department of Health): Accident resulting in a burn to the body surface. 415.4(b)(4)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/15/17, the facility did ensure that services provided or arranged by the facility as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's plan of care. One (Resident #189) of two residents observed for implementation of care for resident's with behaviors had an issue involving staff not utilizing two staff members for bed mobility and toileting as per the resident's plan of care. The finding is: 1. Resident #189 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/7/17 revealed the resident is severely cognitively impaired, is sometimes understood, and rarely/never understands. The resident requires extensive assistance of two or more persons for bed mobility and for toilet use. In addition, the MDS documented the resident is frequently incontinent of urine and always incontinent of bowel. Review of the undated Certified Nurse Aide (CNA) Care Guide (used by the CNA to provide care) included Bed Mobility: extensive assistance; Two + (plus) person physical assist; Toilet Use: extensive assistance; Two + person physical assist. In addition, the CNA Care Guide noted the resident can be combative. Review of the Physical Therapy (PT) Therapist Progress & Discharge Summary dated 7/13/17 included, PT recommends the following levels of assistance upon discharge to long term care: Bed Mobility: Extensive (EXT) assist x (times) two (persons). Review of the Occupational Therapy (OT) Therapist Progress & Discharge Summary dated 7/17/17 included, Nursing recs (recommendations) on unit are as follows: Total/Toileting: Total x two. Review of the undated Care Plan Activity Report included, has history (hx) of physical aggression towards staff and is physical at times during routine care. Review of CNA Documentation History Detail dated 8/15/17 through 9/15/17 it was documented approximately 50 instances of behaviors that included, resists care, repetitive physical movements, kicking/ hitting, pinching / scratching/ spitting, and yelling/ screaming. During an observation of morning care performed by CNA #3 and observed by the Registered Nurse (RN) MDS Coordinator on 9/13/17 at approximately 9:35 AM, the resident was supine (lying flat on back) in bed when CNA #3 untabbed the resident's brief, the resident was incontinent of a moderate amount of soft stool. CNA #3 proceeded to raise right the resident's buttock off the bed, rolled the resident slightly on to her left side, and washed the residents right hip and buttock. CNA #3 then stated, I'm going to roll you onto your side so I can clean you up. When interviewed by the Surveyor regarding the Bed Mobility section of the CNA Care Guide, CNA #3 stated, the two assist is just for boosting the resident up in the bed, I normally do her alone except for the boost. Request for two-person physical assist was made by the Surveyor on 9/13/17 at approximately 9:49 AM. Interview with the Director of Rehab on 9/13/17 at approximately 10:16 AM revealed bed mobility included rolling and boosting in bed. The Director of Rehab also stated that recommendations are made with the residents and staff safety in mind taking into consideration a residents' behaviors with hands on care. Interview with the RN MDS Coordinator on 9/14/17 at approximately 10:02 AM revealed, Bed mobility is everything from assisting with legs in and out of bed, boosting, side to side, if butt (buttocks) in/on the bed, it's bed mobility. If the Care Plan says two assists, then staff needs to use two assist. Interview with the Director of Nursing (DON) on 9/14/17 at approximately 1:51 PM revealed, the Care Plan needs to be followed, once therapy makes a recommendation it needs to be followed and we can't use less assistance than what's on the Care Plan. 415.11(c)(3)(ii)

Based on interview and record review conducted during a Complaint Investigation (Complaint # NY 267) conducted during the Standard Survey completed on 9/15/17, the facility did not provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. One (Resident #209) of ten residents reviewed for pharmaceutical services had issues with the transcription, and the administration of physician ordered medications. Specifically, there was a transcription error for an antibiotic ordered for the treatment of [REDACTED]. The finding is: 1. Resident # 209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 5/5/17 revealed that the resident was cognitively intact. The MDS documented that the resident required extensive staff assistance for toilet use, was frequently incontinent of bladder and was treated for [REDACTED]. Review of the medical record revealed the resident was treated on 4/27/17 with oral antibiotics, 5/27/17 with oral antibiotics and 6/22/17 with oral antibiotics for UTI's identified through urine cultures and prolonged urinary symptoms. Review of a Nurse Practitioner (NP) progress note dated 6/26/17 revealed the resident was seen for the medical management of dysuria (painful urination) and UTI. Staff reported complaints of burning and frequency with foul smelling concentrated urine. The resident was treated on 5/30/17 with Macrodantin (antibiotic) and Cipro (antibiotic) for a UTI. The resident again is complaining of burning with urination, frequency and urgency. A urine culture on 6/20/17 revealed 500,00 units (normal 0-few) E. Coli (Escherichia coli- bacteria found in stool) and Macrodantin was ordered. The assessment plan revealed the resident has current signs and symptoms of UTI and is on Macrodantin 100 milligrams (mg) four times a day for seven days and the resident's dysuria is chronic. Treatment plans included to continue pyridium (urinary analgesic) and for staff to monitor the resident for her chronic and intermittent UTI's, encourage adequate fluid intake, continue Keflex (antibiotic) 250 mg every evening, Cranberry (used for prevention and treatment of [REDACTED]. The resident was seen by urology for consultation on 4/18/17 and had a planned urology appointment on 8/1/17. Review of a Nursing Progress Note dated 7/11/17 at 2:08 PM revealed the resident was seen by the NP for fatigue and lack of appetite on that day. The NP provided orders for a straight catheterization (tube placed into the bladder to collect urine) Urine Culture and Sensitivity (C&S), vital signs every four hours for 24 hours and Complete Blood Count (CBC)/Basic Metabolic Profile (BMP) in the morning. Review of a NP Progress Note 7/12/17 revealed the resident was seen for medical management of cardiac problems (A-Fib, Atherosclerotic Heart disease, Trans Ischemic Attacks (TIA-temporary loss of blood flow to the brain), hypertension, [DIAGNOSES REDACTED]), UTI's and congestive heart failure. A family member reported that the resident is tired and is not acting like herself. Staff reported that the resident has not had complaints of burning, frequency and they have not noticed any foul-smelling urine. The NP documented that a urine C&S was ordered via straight catheterization and will treat the resident as indicated. Review of a Urine Culture report revealed the sample was obtained on 7/12/17 and the results were faxed/sent to the facility on [DATE] at 2:00 PM. The NP reviewed the report on 7/17/17 which revealed E. Coli 200,00 col/ml and Strep Alpha 200,00 col/ml. A handwritten notation on the report documented, Rocephin (antibiotic) 1 gm (gram) IM (intramuscularly) may mix with 2.1 cc (measure of volume) 1% (percent) lidocaine (used to treat pain from some procedures) every twelve hours for seven days. Review of the nursing Progress Notes dated 7/13/17 through 7/17/17 revealed the following: - 7/13/17 at 5:28 PM revealed the resident did not eat or drink and at 10:04 PM revealed the resident was found on the floor without injuries while toileting herself. - 7/14/17 only pertained to an evaluation for the fall and did not contain any clinical information about the resident on that day. - There is no nursing documentation for 7/15 & 7/16/17 as well. - 7/17/17 at 4:05 PM a nursing Progress Note indicates the resident was alert with confusion, appetite good, denies any complaints of pain. Review of the physician's orders [REDACTED]. During an interview on 9/14/17 at approximately 3:12 PM, the Registered Nurse (RN) Unit Manager (UM) (#3) stated that Unit 2 A has two RN Unit Managers and both were sitting at the nurses' desk. Each RN thought the NP was talking to other thus the order for the Rocephin was not transcribed on 7/17/17. The RN #3 Unit Manager stated that the RN Unit Managers and LPNs (Licensed Practical Nurses) enter all provider orders in the electronic medical record. RN #3 UM stated that laboratory (labs) results are placed in the provider's folder for review. Once the provider reviews the labs, they hand the laboratory slip with the orders to the nurse. RN # 3 UM stated she did not recall seeing the order. The RN # 3 UM stated that she found the lab slip with the Rocephin order in the medical record on 7/19/17; after she was alerted that the resident was having shortness of breath. The RN #3 UM notified the NP and obtained orders for the Rocephin stat. The Rocephin is a stock medication in the facility and easily obtainable. Review of a Licensed Practical Nurse (LPN #1) nursing Progress Note dated 7/19/17 at 11:51 AM revealed the resident was dizzy and her blood pressure (B/P) was 140/108 (normal approximately 120/80), heart rate (HR) - 86 (normal 60 to 100 beats a minute), respirations - 22 (about 10 - 15 breaths per minute), temperature - 9.1 (normal 97.7-99.5 °F). Vital signs were repeated with the head of the bed elevated and were documented as B/P 140/90, HR - 86-103, respirations - 24, pulse oxygenation (PO2)- 84 % (normal 95 percent to 100 percent) on room air. The RN was notified and PRN (as needed) O2 (oxygen) was administered with good effect, BP 138/88, HR 78, Respirations 18, and O2 SAT (PO2)- 92%. Review of a RN Nursing Progress Note dated 7/19/17 at 2:51 PM revealed the NP was notified and an order was received for Rocephin 1 gram IM every 12 hours for seven days, dose administered now. Review of a physician's orders [REDACTED]. - 7/19/17 at 2:44 PM, revealed an order for [REDACTED]. - 7/19/17 at 2:47 PM, revealed an order for [REDACTED]. - 7/19/17 at 2:49 PM, revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on 9/14/17 at approximately 2:45 PM, LPN #1 stated that she saw the resident on 7/17/17 and noted that she was alert with some confusion and next saw the resident on 7/19/17. LPN #1 stated that the resident reported to the CNA that she felt dizzy, so she took the resident's vital signs which revealed a low oxygen saturation (O2), she gave the resident some O2, and reported her findings to the RN. LPN #1 stated the resident was afebrile (without fever) and verified that she gave the resident a STAT (now) dose of Rocephin in the afternoon. Review of a LPN #2 nursing Progress Note dated 7/19/17 at 9:52 PM revealed the resident was very short of breath, pulse oxygenation (PO2) was between 66-74%, oxygen at 2 L (liters) was applied and the PO2 saturation improved to 82%, the nurse increased the oxygen to 4 L and the PO2 saturation improved to 92%. The Supervisor and medical on-call was notified. Review of a nursing Progress Note dated 7/19/17 at 11:54 PM revealed the family was updated and came to the facility. The family requested the resident be transferred to the hospital; the paperwork was prepared and resident was sent out at 9:45 PM to the emergency department. During an interview on 9/14/17 at approximately 3:24 PM, LPN #2 stated that she recalled the resident wasn't breathing well and after taking care of the resident she called the Supervisor and medical provider. LPN #2 stated that she believed she saw the resident after dinner. After LPN #2 reviewed the medical record she stated that she administered the resident's 9:00 PM medications and the IM Rocephin. LPN #2 stated the resident was sent out to the hospital not long after that encounter. During an interview on 9/14/17 at approximately 9:40 AM with the NP and attending Physician, the NP stated that on 7/12/17 she saw the resident for her medical problems, including a UTI. The NP stated the resident had a significant history of UTI's and was followed by a urologist. The NP recalled she ordered increased fluids, on that date the resident's white blood count was 6.8 (normal 4,500-10,000 white blood cells per microliter (mcL). Therefore, even if something cultured out in the urine, at that point she probably wouldn't have treated it. The attending Physician added that he probably would not have ordered an antibiotic unless the resident was showing signs of other problems. The NP stated that the Rocephin order did not get transcribed on 7/17/17 because each RN Unit Manager thought the other one was entering the order. At this facility, the nurses enter the orders in the electronic medical record. The NP recalled on 7/19/17 RN #3 Unit Manager informed her that the Rocephin was not ordered on [DATE]; she could not recall the provision of any other specific clinical information. During an additional interview on 9/15/17 at approximately 12:13 PM, the NP stated that she did not have an issue with the resident receiving the Rocephin at 9:00 PM on 7/19/17 rather than 12:00 AM on 7/20/17 because she wanted the resident to get the antibiotic medication on board since she missed doses from transcription error. During an interview on 9/14/17 at approximately 11:29 AM, the Director of Nursing (DON) stated most of the orders in the facility are verbal and the nurses enter them in the electronic medical record. In this case, there were two RN Unit Managers and each one thought the other was placing the order in the record. Regarding the 9:00 PM 7/19/17 Rocephin administration, the RN DON stated that the July MAR indicated [REDACTED]. Based on the orders in the record, the next dose of Rocephin after the initial STAT dose was to be on 7/20/17 at 12:00 AM. Review of the facility's policy entitled Physician Verbal/Telephone Orders dated 1/1/15 revealed that verbal/telephone orders are received by a Licensed/Registered Nurse and entered exactly as stated by the physician. Review of the hospital Emergency Department record revealed on 7/19/17 the resident arrived in respiratory distress. The physician notes determined that the resident had acute respiratory distress with altered mental status due to sepsis and the resident was admitted to the Medical Intensive Care Unit. 415.18 (a)

Based on observation, interview, and record review conducted during a Standard survey completed on 9/15/17, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Two (Resident #96, Resident #210) of five residents observed for infection control practices during activities of daily living (ADL's) had issues with the lack of proper hand hygiene, the lack of proper disinfecting of a shared shower chair and the lack of proper disposal of contaminated linens. The findings are: 1. Resident #96 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Observation on 9/13/17 at approximately 10:15 AM revealed that resident was being transferred from bed to a shower chair. The resident was incontinent of urine. CNA #1 removed the resident's wet brief and placed it on the end of the bed (without a barrier). CNA #1 cleansed the resident's groin and peri area with a wet washcloth. CNA #1 placed the soiled washcloth on the brief. CNA #1 then rolled up the wet brief with the soiled washcloth and placed it on the over the bed table. There was no barrier between the table and the soiled brief and washcloth. While wearing the same gloves to provide incontinence care CNA #1 attached the resident's sling to the Hoyer (a mechanical lifting device) lift and used the remote control. CNA #1 did not change her gloves and her hands were not washed after providing incontinence care. Interview on 9/13/17 at approximately 10:30 AM with CNA #1 she stated that she should have put a barrier on the over the bed table before putting the wet brief and soiled washcloth on it. CNA #1 also stated she should have washed her hands after providing incontinence care. Interview on 9/13/17 at approximately 10:35 AM with Registered Nurse (RN #1) Unit Manager revealed that she expected her staff to place a barrier on the bed or put the soiled items in a garbage bag and that she expected her staff to wash their hands after providing incontinence care. Interview on 9/15/17 at approximately 7:30 AM with the Director of Nursing (DON) revealed that their process during incontinence care is that staff is to place a barrier at the end of bed to place the soiled linens. The DON also stated she expected her staff not to place soiled linens on an over the bed table. She also expected her staff to wash their hands after providing incontinence care. Review of the facility policy and procedure (P&P) entitled Incontinent Care dated 1/1/15 revealed that staff should remove brief and clothing and placed on a soiled barrier pad at the foot of the bed. The P&P also stated that to remove gloves and wash hands after completing incontinence care. 2. Observation on 9/13/17 at approximately 6:55 AM revealed Resident #210 was seated in a shower chair and being assisted by CNA #5. CNA #5 placed the resident over the toilet while seated in the shower chair. Continued observation revealed the resident remained seated over the toilet until approximately 8:00 AM. When CNA #5 removed the resident from over the toilet; observed was a large amount of liquid brownish black stool which covered the entire bottom of the toilet and had splattered the sides of the toilet bowl. Continued observation revealed CNA #5 transported the resident to one of the Ground Floor Shower Suites at approximately 8:05 AM and showered the resident seated on the shower chair. At approximately 8:20 AM the resident, was still seated in the shower chair and was placed over the toilet in shower room after her shower. The resident passed a small amount of liquid brown stool, which was also visible on the toilet seat and CNA #5 used three washcloths to cleanse the resident and placed the fecal soiled washcloths on a barrier. Continued observation revealed CNA #5 began dressing the resident and the resident again requested to go to the bathroom at approximately 8:40 AM. CNA #5 again cleansed the resident and discarded an additional three fecal soiled and blood tinged washcloths and used towel on a barrier. At approximately 8:53 AM, CNA #5 gathered the soiled linens still wearing the gloves used during personal care; opened the shower suite door; walked down a hallway to a Storage Room which had three bins for linens. There was no sink in this Storage Room. CNA #5 opened the bundle of linens and sorted the personal laundry from the soiled washcloths, removed the soiled gloves and walked back into the shower room and washed her hands for five seconds. CNA #5 transported the resident to the dining room at approximately 9:09 AM and the soiled shower chair was not cleaned. In addition, an immediate inspection of the Ground Floor Unit revealed the unit has two soiled rooms which are equipped with a sink. Additional observation on 9/13/17 at approximately 10:30 AM revealed CNA #5 cleaned the shower chair with bleach wipes. Observation revealed when CNA #5 was finished cleaning the chair, the underside ledge (which functionally allows for the placement of a bowl/receptacle for stool) had a copious amount of brown debris on the two ledges. When CNA #5 was cleaning the shower chair, the Housekeeping Director and a general housekeeper entered the shower room and asked who requested decontamination of the shower room. The two workers (Housekeeping Director and the housekeeper) generally cleaned the shower stall, tub area and floors; they did not clean or inspect the shower chair. When the cleaning staff were in the hall, the surveyor took the Housekeeping Director back in the shower suite to inspect the shower chair. The Housekeeping Director stated, the shower chair was not in a clean condition for use for another resident and further stated that it is the responsible of the CNA's to clean the shower chair. During an additional observation of the shower chair on 9/13/17 at approximately 10:55 AM with the Registered Nurse (RN#5) Unit Manager present the shower chair still had copious amounts of brown debris under the ledges. The RN #5 Unit Manager stated that the equipment was not decontaminated properly and that it is the responsibility of the CNA's to clean the shower chairs. RN #5 also stated the resident was taken off [DIAGNOSES REDACTED] (Clostridium difficile - bacterial infection in the stool that may cause diarrhea) precautions on 9/11/17 and she was not aware the resident was having loose stool again. During an interview on 9/13/17 at 11:01 AM, CNA #5 stated it is the responsibility of the CNA's to clean the shower chairs and they are also cleaned by the housekeeping staff on the third shift daily. CNA #5 stated she did not clean the shower chair immediately after use because there were no bleach wipes on the floor and she had to get them delivered. During an interview on 9/15/17 at approximately 9:30 AM, the RN Infection Control Nurse stated that staff are expected to follow universal precautions when providing resident care and that unit staff separate personal linens from institutional linens for washing purposes. The RN Infection Control Nurse was not aware that the Ground Floor Unit utilized two Storage Rooms not equipped with sinks to discard and house soiled linen receptacles. Review of the facility's entitled Policy on Universal/Standard Precautions dated 1/1/15 revealed that Universal/Standard precautions are used all times based on the principal that blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes of all residents are considered potentially infectious and include the use of hand hygiene, and the care of the environment, textiles and laundry. 415.19(a)(1)(b)(4)(c)

Based on interview and record review conducted during an Abbreviated survey (complaint #NY 228) completed on 11/3/14, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #1) of three residents reviewed for quality of care had issues involving the failure of nursing staff to follow the facility's bowel protocol, lack of communication between nursing staff regarding the resident's bowel status, and failure to notify the Physician or Nurse Practitioner (NP) of the resident's lack of a bowel movement for seven days. The resident was transferred to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The resident required an emergent total colectomy (a surgical procedure to remove all of the large intestine/colon) and [MEDICAL CONDITION] (a surgical opening in the abdomen to remove waste from the body). This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 8/4/14 revealed the resident is cognitively intact, understands and is understood. Resident #1 stated during an interview on 10/22/14 at approximately 11:30 AM that she just got back from the hospital yesterday. When asked why she was at the hospital the resident stated that she couldn't move her bowels for a few days and was "backed up." The resident stated she could not remember the exact number of days she went without a bowel movement (BM). When asked if she told the nursing staff about her bowels the resident stated that she did tell the nursing staff. The resident said "I guess there was nothing they could do about it and now I have a "[MEDICAL CONDITION]" (surgical creation opening into colon). Review of nursing Progress Notes dated from 9/24/14 through 10/7/14 revealed no documentation of the resident's BM status until a note dated 10/7/14 at 7:35 AM written by the Registered Nurse (RN) Supervisor. The note revealed the RN was called to assess the resident at 5:15 AM and that the resident's abdomen was grossly distended. Staff reported that the abdomen was normal when they saw the resident during 1:00 AM rounds. The resident's temperature was 101.3 (normal 98.6), pulse 122 (average 80), respirations were 24 (normal 12-20) and blood pressure 180/96 (normal 120/80). There was some firmness to the abdomen and no bowel sounds were auscultated (heard) in any quadrant. The resident demonstrated no discomfort with palpation (touch) but reported a sharp pain across the abdomen extending down the left abdominal quadrant. The resident reported she had a "little" nausea and denied vomiting or diarrhea. The resident reported no BM for "a few days". The NP was notified and an order was received to transfer the resident to the emergency room (ER). The resident was transferred to the ER by ambulance at 6:20 AM. Review of a nursing Progress Note dated 10/7/14 at 2:37 PM written by the Licensed Practical Nurse (LPN) revealed that the resident was admitted to the hospital with [REDACTED]. Review of the facility's bowel records revealed the resident had a BM on 9/21/14, 9/22/14, 9/23/14 and 9/25/14. The resident did not have a BM on 9/26/14, 9/27/14, 9/28/14, 9/29/14, 9/30/14, 10/1/14 and 10/2/14. The resident had a large loose BM on 10/3/14 and no BM on 10/4/14, 10/5/14, 10/6/14 and 10/7/14. Review of the resident Medication Administration Records (MARs) for September 2014 and October 2014 revealed the following bowel medications ordered for constipation: - Senna S 50 mg (milligrams) 8.6 mg tablet three tablets by mouth two times per day. - [MEDICATION NAME] 17 gm (gram) powder by mouth once daily (PRN) as needed. Mix with 120 ml (milliliter) of water or juice. - Milk of Magnesia (MOM) 30 ml by mouth once daily PRN. - Fleet Enema insert one rectally every three days PRN if no BM . Further review of the MARs for September 2014 and October 2014 revealed the resident was administered the following PRN bowel medications: [REDACTED] - 9/27/14 at 9:43 PM one dose of [MEDICATION NAME]. - 9/29/14 at 7:50 AM one dose of [MEDICATION NAME]. - 9/30/14 at 7:22 PM one dose of [MEDICATION NAME]. - 10/1/14 at 11:15 PM one dose of MOM. - 10/3/14 at 1:30 PM one dose of MOM. Review of the facility policy and procedure entitled Bowel Program/Constipation dated 5/28/09 revealed the following: - The attending Physician will be contacted if a resident does not have a BM for a 72 hour period and/or does not have orders for bowel treatments for constipation. - Facility PRN Medication Orders and Treatment Regimen: Day 1 Intervention only, PRN (per resident request) Day 2 (Evening) PRN laxative as ordered Day 3 (Nights) PRN suppository as ordered Day 3 (Days) PRN Fleets as ordered Day 4 (Days) S.S.E. as ordered (Soap Suds Enema). Interview with the Assistant Director of Nursing (ADON) on 10/22/14 at approximately 11:00 AM, the ADON stated that at the end of September the facility changed from hand written to computerized bowel monitoring records. The ADON stated that there was no documented evidence that the resident had a BM on 9/26/14, 9/27/14, 9/28/14, 9/29/14, 9/30/14, 10/1/14, 10/2/14, 10/4/14, 10/5/14, and 10/6/14. Interview with the RN Unit Manager (UM) on 10/22/14 at approximately 12:30 PM, the RN UM stated that she was not aware that the resident did not have a BM for seven days from 9/26/14 through 10/2/14. She stated that on a daily basis she reviews a list of residents in need of bowel interventions and the resident was not on the list. Nothing was mentioned to the RN during morning report about the resident's lack of a BM. LPN staff did not report to her that the resident had not had a BM in seven days. The RN UM stated that she did not report the lack of a BM to the Physician or NP since she was not aware of the situation. She stated that normally she would let the Physician or NP know if a resident did not have a BM in three days especially if there was no BM after a Fleets enema was administered. The RN UM stated that she was aware the resident did not have a BM on 10/4/14, 10/5/14 and 10/6/14 prior to the hospitalization on [DATE]. Interview with LPN #1 on 10/22/14 at approximately 12:45 PM, LPN #1 stated that she works full time day shift from 7:00 AM through 3:00 PM on Unit 2-B . She stated that she was not aware that the resident did not have a BM from 9/26/14 through 10/2/14. She stated that if she had been aware she would have addressed it. She was familiar with the facility's bowel protocol. LPN #1 stated that normally the RN UM or Nursing Supervisor would call the Physician or NP after an issue concerning a resident is brought to their attention. Telephone interview with LPN #2 on 10/27/14 at approximately 10:30 AM, LPN #2 stated that she works full time on the night shift from 11:00 PM through 7:00 AM on Unit 2-B. She stated that she worked on 9/28/14. She stated that she reviews bowel records each shift to determine which resident's need a bowel intervention and is aware of the facility's bowel protocol and interventions. LPN #2 stated that on 9/28/14 the resident was not on the list of residents that had not had a BM so she did not administer an intervention to the resident. Telephone interview with LPN #3 on 10/27/14 at approximately 10:30 AM, LPN #3 stated that she works full time on the day shift from 7:00 AM through 3:00 PM as a float nurse. She stated that she floats to all units in the facility. LPN #3 stated that she worked on Unit 2-B on 9/29/14 and stated that the resident had not had a BM in a few days so she asked the resident if she wanted [MEDICATION NAME] and the resident said yes. LPN #3 stated that she believes she offered the resident a Fleets enema but the resident refused it. She stated she did not document this refusal. She stated that she believes she reported to the RN UM that the resident was given [MEDICATION NAME] and had some emesis during the shift. LPN #3 stated that she did not report anything regarding the resident to the Physician or NP. She stated that normally the RN would contact the Physician or NP after the LPN reports an issue. LPN #3 stated that she administered MOM to the resident on 10/3/14 and the resident had results from it. LPN #3 stated that on 10/3/14 she was not aware that the resident had not had a BM for seven days prior to 10/3/14. She stated that she reviews the bowel records on her residents on a daily basis and is aware of the facility's bowel protocol and interventions. Telephone interview with LPN #4 on 10/28/14 at approximately 10:00 AM, LPN #4 stated that she works two to three days per week on the evening shift from 3:00 PM through 11:00 PM. She stated that she worked on Unit 2-B on 10/1/14 and reviewed the list of residents that needed bowel interventions and believes the resident was on the list. LPN #4 stated that she administered MOM to the resident because the resident requested it. She stated that on 10/1/14 she was not aware that it had been almost six days since the resident's last BM. LPN #4 stated that she is aware of the facility's bowel protocol. She stated that normally the day shift staff give the Fleets Enema, the evening shift gives MOM and the night shift gives the [MEDICATION NAME] suppositories. LPN #4 stated that she did not report any issues to the RN regarding the resident. Telephone interview with the Physician on 10/22/14 at approximately 1:00 PM, the Physician stated that he was not notified by nursing staff of the resident's lack of a BM from 9/26/14 through 10/2/14. He stated that nursing staff should follow the bowel protocol to facilitate a BM. He stated that notification to medical staff would be based on the resident's history but he would expect the nursing staff to notify medical staff if there is no BM after three to four days. He stated that normally the NP would be notified of a bowel issue. Telephone interview with the NP on 10/27/14 at approximately 10:00 AM, the NP stated that nursing staff did not notify her of the resident's lack of a BM from 9/26/14 through 10/2/14. She stated that she would expect staff to notify her of the lack of a BM after a Fleets Enema is given which is usually given on day three of no BM. The bowel medications that were administered to the resident by nursing staff ([MEDICATION NAME] on 9/27/14, 9/29/14 and 9/30/14; and MOM on 10/1/14 and 10/3/14) were reviewed with the NP by this writer. The NP stated that "it appears as though the nursing staff did not follow their bowel protocol." Review of the Hospital Medical Records, Operative Report dated 10/7/14 revealed that the pre-operative [DIAGNOSES REDACTED]. The post-operative [DIAGNOSES REDACTED]. 1. Stercoral Ulcer (an ulcer of the colon due to pressure and irritation resulting from severe prolonged constipation). 2. Sigmoid perforation (a perforation in the colon). 3. Feculent peritonitis (fecal contamination of the gap between the wall of the abdomen and the abdominal organs). Operations performed at the hospital were as follows: 1. Exploratory laparotomy (surgical incision into the abdominal cavity to examine the abdominal organs). 2. Lysis of adhesions (cutting of scar tissue within the body). 3. Abdominal washout (procedure to wash out infected or contaminated fluids). 4. Total abdominal colectomy (removal of part of the colon) with end [MEDICAL CONDITION] (surgical creation of opening into small intestine). Review of the Operative Report documented CT (computerized tomography) scan of the abdomen results of a significant amount of feces in the rectum, sigmoid and ascending colon as well as a large amount of intraperitoneal air (air in the abdominal cavity). The resident was then transferred to another hospital on [DATE] for a higher level of care. Further review of Operative Report revealed there was an approximate two centimeter perforation with spilling of fecal material from the sigmoid colon. The distal sigmoid and the proximal rectum had an "enormous stool burden." The stool was disimpacted from the sigmoid and rectum through the [MEDICAL CONDITION] and that approximately two liters of hard stool was removed from the sigmoid colon and rectum. Review of the Hospital Discharge Summary dictated by a Physician on 10/20/14 revealed that the resident suffered an acute MI ([MEDICAL CONDITION]) after surgery. The resident was discharged from the hospital and readmitted to the long term facility on 10/21/14. 415.12

Based on observation, record review and staff and resident interview, the facility did not ensure that a resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care. Three (Residents #34, 90, 274) of seven residents reviewed for quality of care had issues: Resident #34 had a Foley catheter (tube inserted into the bladder to drain urine) and sustained a urethral slit (an extended slit in the skin originating from the external opening of the urinary tract). The catheter tubing was not secured during care and the resident experienced pain. This resulted in actual harm that is not immediate jeopardy. Resident #90 had a blood glucose level obtained after eating a meal which was not in accordance with the physician's orders [REDACTED]. There was no actual harm with potential for more than minimal harm for Residents #90 and 274 that is not immediate jeopardy. The findings are: 1. Resident #34 has a [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident has moderate cognitive impairment. During an interview on 3/21/12 at approximately 10:00 AM, the Licensed Practical Nurse (LPN) Unit Manager stated that Resident #34 is interviewable. Review of an Interval Note, written by the Attending Physician, dated 8/18/11 revealed that Resident #34 is a "normal uncircumcised male". The Physician documented that a Foley catheter (to gravity) was in place and there were superficial erosions on the foreskin. Review of an Interval Visit, written by the Family Nurse Practitioner (FNP), dated 10/21/11 revealed the Foley catheter was discontinued and the resident was voiding on his own. The FNP documented that an area of skin erosion at the meatus (external opening of the urinary tract) of the male genitalia was healed. Review of a Comprehensive Interval Exam (completed by the Attending Physician) dated 12/20/11 and a Medical Clearance Note (written by a Physician Assistant) dated 3/16/12 revealed the GU (genital / urinary) exam was "deferred". Review of the Comprehensive Care Plan dated 2/9/12 revealed the resident has a history of [MEDICAL CONDITION] and has a Foley catheter in place with an approach to irrigate per policy. Review of a physician's orders [REDACTED]. Review of Treatment Records dated 2/12 and 3/12 revealed [MEDICATION NAME] II cream (combination antifungal and steroid cream) was applied topically to the rim of the male genitalia twice a day for excoriation and was discontinued 3/7/12 because the area was healed. During an observation on 3/23/12 at 10:31 AM, a certified nurse aide (CNA #1) provided personal care to Resident #34. The CNA was observed to reposition the Foley drainage bag containing yellow urine and the catheter leg strap which was loose, moved on the resident's leg. The CNA cleansed the resident's genital area and a meatal slit (urethral slit) was observed extending from the urinary meatus, approximately 1 to 1 1/2 inches on the posterior (the back of) male genitalia. The Foley catheter was pulled posterior into the slit and the resident grimaced when the area was cleansed. At 10:46 AM, the resident turned onto his right side and the Foley drainage bag remained on the left side of the bed. The catheter tubing was pulled taut and the resident was observed to grimace. Observation on 3/23/12 at 11:23 AM revealed CNA #1 removed the catheter bag from the left side of the bed and hung it on the end of the bed. CNA #1 was observed to provide range of motion (ROM) exercised to the resident's left lower leg and the Foley catheter was observed to be pulled taut and the resident grimaced. CNA #1 was observed to remove and reapplied the Velcro strip securing the Foley tubing to the leg strap but did not readjust the loose leg strap. CNA #1 continued to provide ROM and the Foley catheter was observed to remain taut. There was an approximate one to one and a half inch gap between the resident's leg and the leg strap. During the observation, the leg strap moved from the top of the resident's left leg to the back of the leg; the leg strap was pulled taut; and the resident intermittently grimaced during the ROM. At 11:26 AM, the CNA removed and reapplied the leg strap and positioned the catheter tubing on the inner aspect of the resident's left leg. During an observation on 3/23/12 at 11:47 AM, CNA #1 placed the Foley drainage bag on a bar on the left side of the resident's rolling walker. The resident was observed to ambulate with the rolling walker from his room to the main dining area on the unit, a distance of approximately 200 to 250 feet. The Foley catheter tubing was observed to pull up the bottom of the resident's pant leg as he walked and the tubing was pulled taut. The CNA transferred the resident into a wheelchair and observation of the catheter tubing revealed there was blood in the resident's urine. During an interview on 3/23/12 at 11:57 AM, CNA #1 observed the hematuria (blood in urine) in the Foley catheter tubing and stated the resident recently had a procedure and has had bleeding and blood clots in the Foley catheter. When interviewed on 3/26/12 at 11:42 AM, CNA #1 stated that Resident #34's leg strap slides down and that a leg bag would keep that from happening. CNA #1 stated he was not aware that the leg strap was loose until the end of the resident's care on 3/23/12. The CNA stated that he had not cared for Resident #34 in approximately six weeks; the meatal slit had "been that way", and "it may be bigger". CNA #1 stated that he told a Treatment Nurse about the meatal slit but does not remember who or when he told them. During an interview on 3/23/12 at 3:36 PM, the resident stated that he has a tumor in his bladder and that is why he has the Foley catheter. The resident stated it hurt when the CNA cleansed around the catheter today and "It hurts most of the time when they clean around the catheter". The resident stated that it hurts when they pull back on the foreskin to apply ointment. The resident stated he was supposed to have the catheter taken out yesterday after his procedure, but it did not "pan out", "I sure would like the catheter out". The resident also stated the catheter feels like it is being pulled when he walks. Review of Urology Consults dated 1/3/12 and 3/21/12 revealed the resident had a Foley catheter due to [MEDICAL CONDITION]. There was no documentation regarding the meatal slit. During an interview on 3/23/12 at 3:57 PM, the Evening Shift LPN stated that when he received report today, he was told to monitor the catheter for hematuria and "that was really it". The LPN stated he was not aware of any problem or trauma with the Foley catheter. An interview with the Registered Nurse (RN) Supervisor/ Skin Nurse on 3/23/12 at 4:15 PM revealed she was not aware of any skin issues for Resident #34 and the RN asked "Is there a problem?" During an observation on 3/23/12 at 4:30 PM, the RN Supervisor/ Skin Nurse assessed the insertion site of Resident #34's Foley catheter by pulling back the foreskin and the RN stated "The whole thing is open". The RN measured the meatal slit and stated it was 1.8 centimeters (cm) long. The RN Supervisor/ Skin Nurse did not assess the resident's pain at this time. During an interview on 3/23/12 at 4:34 PM, an Evening Shift CNA (CNA #3) stated she provides HS (hour of sleep) care to Resident #34. The CNA explained that she cleanses the resident's genitalia by pulling back the foreskin and cleaning around the Foley catheter. The Evening Shift CNA stated that she did not notice anything abnormal at the catheter insertion site and stated she did not notice a slit in the meatus. When interviewed on 3/26/12 at 10:38 AM, the Physician Assistant ( PA) stated he did not recall any problem with Resident #34's Foley catheter or that the resident had a meatal slit. The PA stated standard protocol would be that when the resident is ambulated, he would have a leg bag on. The PA also stated "Ambulating the resident from his room to the dining area without a leg bag on would be too far. The nurses should be picking up on that and apply a leg bag". During the interview, the PA stated that the physician would be in the facility tomorrow and needs to evaluate the resident's meatus to assess if it is stretching or is a tear. The PA explained that if it is a tear, it has to be evaluated to see if it needs surgical repair. During an interview on 3/26/12 at approximately 11:00 AM, a Day Shift CNA (CNA #2) who had previously cared for Resident #34 on a routine basis, stated when she provided catheter care to the resident, she pulled back the foreskin and cleansed around the catheter insertion site. CNA #2 stated that she did not see a meatal slit. During an interview on 3/26/12 at 3:00 PM, the RN Relief Unit Manager stated that "the resident is going to see the Urologist tomorrow". The RN stated she is sending a communication note to the Urologist to assess the meatal slit to see if anything can be done about it. Interview with the Attending Physician on 3/26/12 at 4:22 PM revealed he did not have a recollection that Resident #34 had a meatal slit. The Physician stated the resident should have a leg bag to keep the Foley from pulling when ambulating. The Physician stated there is catheter pressure on the meatus when the resident is turned in bed, no matter what direction the resident is turned to. The Physician stated now that there is a meatal slit "I will get the Foley out". The Physician explained that if the resident previously had a meatal slit, he would be vulnerable for a meatal slit to recur. Review of the 1/3/12 Urology Consult with the Physician revealed the resident had retention of urine caused by clots. The Consult documented the urine showed no more clots, but the resident wished to keep the Foley catheter. The Physician stated "It upsets me that this has occurred. The resident should have had a leg bag and there should be documentation that the resident was asked if he wanted a Foley. I am sorry this happened to the resident". During an interview on 3/27/12 at 8:27 AM, the resident stated that when he saw the Urologist in 1/12, he did not ask the physician to leave the Foley in. The resident stated his Physician has never talked to him about the Foley catheter. The resident stated he is going to get the Foley catheter out and wants it out. During the interview, the resident stated that he knew there was a slit on his genitalia. The resident stated he did not know how long the meatal slit has been there and "It is not healing up either". The resident stated the catheter hurts when it is cleansed or he moves in bed. During an interview on 3/27/12 at 2:38 PM, the Physician stated "I will not make a case that a catheter being pulled during ROM or care did not cause pain". The Physician stated a catheter pulled into a meatal slit is "not going to be a good thing". Review of a facility policy entitled Catheter, Care of and Supplies dated 8/08 revealed to prevent meatal irritation, a leg band can be rotated 1 inch in one direction and 1 inch in the other direction every 4 to 6 hours. Alternating legs periodically may also add to resident comfort. 2. Resident #90 has a [DIAGNOSES REDACTED]. Review of a physician progress notes [REDACTED]. Review of an Addendum to the 3/19/12 Progress Note dated 3/20/12, revealed the Physician, Family Nurse Practitioner and Unit Manager saw the resident on rounds, the FS results were reviewed and adjustments were made. Review of an undated physician's orders [REDACTED]. During an interview on 3/23/12 at 8:25 AM, the resident stated she ate a Danish, yogurt and coffee for breakfast on 3/23/12. At this time, a Licensed Practical Nurse (LPN) Medication Nurse was observed to obtain a FS BG reading of 223 and stated "That is high". The LPN Medication Nurse was observed to document on the Medication Administration Record (MAR), that the FS BG was obtained at 7:00 AM. When interviewed on 3/23/12 at 2:08 PM, the LPN Medication Nurse stated AC is before meals and the FS BG should have been done at 7:00 AM. The LPN stated that she documented on the MAR, that the FS BG was done at 7:00 AM. The LPN stated she does not document the actual time done if it is different than the actual time ordered; she stated that she should and will put a note in the computer. The LPN Medication Nurse stated the FS BG was not accurate because it was done after the resident's meal. The LPN explained that the Physician is monitoring Resident #90's FS BG for five days because the "blood sugars were all over the place". During an interview on 3/28/12 at 1:13 PM, the LPN Unit Manager stated that the resident's FS BG's were being followed closely because the resident is receiving an antibiotic for an infection of the left hip. The LPN Unit Manager explained that the resident's FS BG's have gone up in the past when she was on an antibiotic. The LPN Unit Manager stated the FS BG should be checked before a meal and if it is done after the meal, it could give a high reading. The LPN explained that the Physician is making adjustments to the resident's insulin based on the AC FS BG results and she would inform the Physician that the FS BG was obtained after the resident's breakfast on 3/23/12. 3. Resident #274 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident has severe cognitive impairment. On 3/21/12, a Weekly Skin/Wound Sheet with entries dated 12/27/11 to 2/28/12 was reviewed. The assessment dated [DATE] was initialed by an RN (#2) and documented that the resident had a facility acquired, widespread reddened area on the left and right buttocks. There was no measurement of size. Review of a physician's orders [REDACTED]. Observation during personal care on 3/23/12 at 12:22 PM, revealed the resident had a reddened area over both buttocks. The right buttock had two areas, measuring approximately 4 centimeters (cm) long (L) by 2 cm wide (W) and 0.5 cm L by 0.5 cm W, that had dry, crusted skin. The left buttock had an approximate 0.5 cm L by 0.5 cm W area of dry, crusted skin. Additional review of the Weekly Skin /Wound Sheet (containing entries for 12/27/11 to 2/28/12) on 3/23/12, revealed there were additional entries initialed by RN #2 dated 3/7/12 and 3/22/12 documenting a widespread reddened area on both buttocks on 3/7/12 and a "reddened buttock" on 3/22/12. The 3/7/12 and 3/22/12 entries were not present when the sheet was reviewed on 3/21/12. During an interview on 3/23/12 at 2:02 PM, the Registered Nurse (RN) Supervisor/ Skin Nurse stated the Skin Team is made up of herself, the RN Relief Unit Manager (RN #2) and Dietary. The RN Supervisor/Skin Nurse stated it is her responsibility to evaluate wounds, stage pressure ulcers, evaluate whether a treatment is effective, and document the location, appearance of the wound bed, and if there is drainage. When interviewed on 3/23/12 at 2:18 PM, the RN Relief Unit Manager (RN #2) stated sometimes she does skin rounds alone when the RN Supervisor/ Skin Nurse is not available. The RN Relief Unit Manager stated that she was assigned to the office on 3/7/12 and did not do the skin assessments on the unit. After review of the Weekly Skin /Wound Sheet dated 3/7/12, the RN Relief Unit Manager stated she was told by the RN Supervisor/ Skin Nurse to bring the Weekly Skin assessment current so she took the information from the skin assessment done the week before (2/28/12) and documented the 3/7/12 entry without assessing the resident. The RN Relief Unit Manager stated she looked at the resident's buttocks on 3/22/12 and it was reddened. The RN explained that when she does a skin assessment she should measure area, depth, color, any drainage, and the condition of the surrounding skin. The RN stated she does not always know what stage a pressure ulcer is and will ask the RN Supervisor/ Skin Nurse. The RN also stated she normally measures the area of excoriation. On 3/23/12 at 2:37 PM, the RN Relief Unit Manager was observed to cleanse the resident's rectal area and stated there was "scabbing" on the resident's buttock. The RN Relief Unit Manager stated she does not know what to call the areas on the resident's buttock. The RN stated she does the skin assessments but is learning as she goes. The RN stated that [MEDICATION NAME] was on the resident's buttocks when she looked at the resident on 3/22/12, so she documented that the area was reddened because the area around the [MEDICATION NAME] was reddened. During an observation on 3/23/12 at 2:52 PM, the Assistant Director of Nursing (ADON) assessed the resident's buttocks and stated the entire reddened area was a 7 cm long by 2 cm wide with eschar (dead tissue). The area on the left buttock measured 3.4 cm long by 1.4 cm wide and the right inner buttock area measured .5 cm long by .3 cm wide. The ADON stated she would talk with the physician and the areas will need continuous monitoring. When interviewed on 3/23/12 at 3:17 PM, the ADON stated when a nurse does an assessment she needs to observe the area and document what she sees. The ADON stated the [MEDICATION NAME] needs to be removed to see the resident's skin. During an interview on 3/23/12 at 3:19 PM, the Relief RN Unit Manager stated she should not have documented the Weekly Skin/ Wound sheet without looking at the resident's buttocks. 415.12