Every finding on record at Crown Park Rehabilitation and Nursing Center

Based record review and interview during the abbreviated survey (iQIES #2707916) the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was observed to have a new onsite pressure ulcer of their sacrum (large triangular bone at the base of the spine). There was no documented assessment by a qualified professional, and no documented notification of a medical provider for treatment when it was identified, or during the following day shift. Findings include:The facility policy Notification of Change in Status, revised 05/2025 documented:-The Nurse Managers/Charge Nurse/Nursing Supervisor would be responsible for assessing a resident's condition for significant changes or with any accident/incident.-Any change in condition or accident/incident would be reported to the physician.-Change in condition or accident/incidents would be placed on the 24-hour report with the notification information and any related physician orders. The facility policy Pressure Injuries, revised 11/2025 documented:-A pressure ulcer risk assessment would be done on admission for existing pressure injury and/or risk factors. Repeat the risk assessment quarterly, annually, and upon any changes in condition. Use the Braden Risk Assessment tool to document and assess risk factors.-A skin assessment would be daily when performing or assisting with personal care or activities of daily living. Staff were to evaluate, report and document potential changes in skin. Resident #1 had diagnoses including diabetes mellitus type 2 with unspecified complications, cellulitis (skin infection) of left great toe, and stage 3 pressure ulcer (a wound that extends to the subcutaneous fat tissue) of the sacrum. The 11/03/2025 Minimum Data Set assessment documented the resident's cognition was severely impaired, they were partial to moderate assist for rolling left to right in bed and bed/chair-to-bed transfers, used a wheelchair and they could propel short distances, were not at-risk for pressure ulcers, had no unhealed pressure ulcers, no venous ulcers, and had pressure-reducing devices for their bed and chair. A 10/28/2025 Braden Skin Assessment (a tool to determine pressure ulcer risk) documented the resident had no skin impairment. A 10/29/2025 admission Assessment by Registered Nurse Unit Manager #4 documented the resident's skin was intact and they were at risk for pressure ulcers. The Comprehensive Care Plan, with a start date of 10/28/2025, documented:Interventions for activities of daily living/mobility were weekly skin checks with bathing, wheelchair with leg rests, gel/foam seat cushion and toe offloading shoe on left foot.Interventions for risk for impairment of skin integrity due to diabetes were incontinence management for relief of moisture and fecal contamination, toileting schedule as indicated, weekly skin checks, skin care every shift and as needed, keep skin clean and dry, encourage adequate nutrition intake, and monitor intakes and outputs. Certified Nurse Aide Instructions as of 12/27/2025 documented the resident was supervision or touching assist for rolling left to right in bed and sit to lying, and partial to moderate assist of one person for transfers. They used a wheelchair and had a toe offloading shoe for their left foot. They had a pressure-reducing device for their wheelchair. Physician's Orders from 12/01/2025 to 12/27/2025 did not contain any orders for pressure ulcer treatments prior to the resident going out to the Emergency Department on 12/27/2025. A 12/27/2025 at 10:53 AM Nursing Progress Note by Licensed Practical Nurse #10 documented the resident had an open area on their coccyx (tailbone) that was red in color and had a small area of black in the center. It appeared it may be tunneling. The area was cleansed, foam dressing applied, and the unit manager was notified. There was no documentation evidence on the 12/27/2025 day shift that a Registered Nurse assessment had been completed on Resident #1 or that any orders from a medical provider were obtained. A 12/27/2025 at 8:55 PM Registered Nurse Supervisor #13 progress note documented Licensed Practical Nurse #19 notified them that Resident #1's blood sugar was 504 and they were not at baseline. An assessment of the wound to their coccyx (the specific area later identified as the sacrum) was foul- smelling with gray and brown drainage. Vital signs were taken, and their temperature was 99.9 degrees Fahrenheit, their oxygen saturation on room air was 89% (normal range 95% - 100%), and oxygen was applied. The on-call medical provider was notified at 8:10 PM, and an order was obtained to send the resident to the Emergency Department to be evaluated. A 12/28/2025 at 11:53 AM Licensed Practical Nurse #19 progress note documented the resident had been admitted to the hospital. Their vital signs were stable, a surgical consult was ordered regarding their left great toe ulcer, intravenous fluids were running for dehydration purposes and the wound on their sacrum was documented as an unstageable pressure ulcer of the sacrum, needing packing in the wound bed. The 01/02/2026 Hospital Discharge Summary documented the resident had been admitted to the Emergency Department for hyperglycemia (high blood sugar) and left great toe necrotic wound. Other medical problems managed in the hospital included type 2 diabetes mellitus and stage 3 decubitus ulcer on the sacrum. The resident had a poor prognosis due to multiple comorbidities and was at high risk for readmission. The facility investigation and summary for the 12/27/2025 investigation of Resident #1's sacral pressure ulcer, signed off by the Administrator and Director of Nursing on 01/14/2026 documented:-On 12/26/2025 night shift Certified Nurse Aide #14 observed a skin issue and notified Registered Nurse #12, who was working on the unit. Registered Nurse #12 assessed the sacral wound and applied a treatment. Registered Nurse #12 did not document the skin area in the Nursing Progress Notes and did not notify a medical provider. Registered Nurse #12 reported to the day shift nurse, Licensed Practical Nurse #10, about the area on the resident's sacrum.-On 12/27/2025 day shift Licensed Practical Nurse #10 documented on the skin issue to the sacral area and notified Registered Nurse Unit Manager #4 (who was not in the building), instead of the in-house supervisor, Licensed Practical Nurse #11. Licensed Practical Nurse #10 reported to the evening nurse, Licensed Practical Nurse #19.-On 12/27/2025 evening shift Licensed Practical Nurse #19 reported to Registered Nurse Supervisor #13 that the resident had a change in condition. Registered Nurse Supervisor #13 assessed the resident, noted the sacral wound and was made aware of the hyperglycemia (high blood sugar). The on-call medical provider was notified, and an order was obtained to send the resident to the Emergency Department to be evaluated. During an interview on 01/08/2026 at 2:30 PM with Physician's Assistant #6 they stated the last time they had seen Resident #1 before the sacral pressure area was discovered on 12/27/2025 was on 12/23/2025, when they were evaluating them for recent, uncontrolled hyperglycemia. They were not made aware of any skin issues the resident may have had at that time. The resident's visible skin was clear, dry and intact. A pressure area on a resident's sacrum like Resident #1 had could take a few days to develop and not be discovered until it opened. During an interview on 01/08/2026 at 3:35 PM with Registered Nurse Unit Manager #4 they stated they first heard of the pressure area on Resident #1's sacrum when Licensed Practical Nurse #10 notified them 12/27/2025 in the morning via a text message. They were not working that day, and they did not assess the area. They told Licensed Practical Nurse #10 to have a Registered Nurse assess the area. They did not offer any further direction to Licensed Practical Nurse #10. During an interview on 01/14/2026 at 3:00 PM with Assistant Director of Nursing/Wound Nurse #3 they stated they were notified of Resident #1's sacral pressure ulcer on 01/02/2026 when they were readmitted to the facility. Weekly skin checks were done on residents' shower days by a Licensed Practical Nurse or Registered Nurse. A nurse should have done a Braden Skin Assessment on Resident #1 when the sacral ulcer was discovered on 12/27/2025. During an interview on 01/16/2026 at 9:45 AM the Administrator stated during the facility investigation they discovered Resident #1's sacral pressure ulcer was first assessed by Registered Nurse #12 on night shift (12/26/2025 into 12/27/2025). Registered Nurse #12 did not document on the sacral pressure ulcer and did not notify a medical provider. During an interview on 01/16/2026 at 10:20 AM Certified Nurse Aide #7 stated they cared for Resident #1 on day shift 12/26/2025 and the resident did not have a skin impairment at that time. On 12/27/2025 when they were doing care on Resident #1 before breakfast, they saw a reddened area on the resident's sacrum and notified Licensed Practical Nurse #10. Certified Nurse Aide #14, who had cared for the resident on night shift, did not say anything to them about an area on Resident #1's sacrum. Licensed Practical Nurse #10 came into the resident's room and looked at the reddened area to their sacrum. During an interview on 01/16/2026 at 10:36 AM with Licensed Practical Nurse #10, they stated on the morning of 12/27/2025 Certified Nurse Aide #7 told them about the reddened area on Resident #1's sacrum and how there was a soiled, detached dressing in the resident's incontinence brief. Certified Nurse Aide #14 (night aide) told them they notified Registered Nurse #12 about the reddened area on Resident #1's sacrum. They (Licensed Practical Nurse #10) placed a clean foam dressing on the resident's sacrum and notified Registered Nurse Unit Manager #4, who was not working that day, via a text message about the resident's sacral pressure area. Registered Nurse Unit Manager #4 told them to not write a nursing progress note about the area until a Registered Nurse had assessed the area. They (Licensed Practical Nurse #10) told Registered Nurse Unit Manager #4 there was not a Registered Nurse working day shift that day but there would be on evening shift. At change of shift from days to evenings on 12/27/2025, they notified Licensed Practical Nurse #19 about Resident # 1's sacral pressure area. Looking back on the incident, they should have notified Licensed Practical Nurse Supervisor #11 on day shift 12/27/2025 and the medical provider on-call. During a follow-up interview on 01/16/2026 at 12:20 PM with Registered Nurse Unit Manager #4 they stated Licensed Practical Nurse #10 should have notified Licensed Practical Nurse Supervisor #11 on 12/27/2025, who then would have notified a Registered Nurse to assess Resident #1's sacral area. Licensed Practical Nurse #10 should have also called the on-call medical provider. Both Registered Nurse #12 and Licensed Practical Nurse #10 did not follow the notification chain of command. During an interview on 01/16/2026 at 1:35 PM with Licensed Practical Nurse Supervisor #11 they stated Licensed Practical Nurse #10 never notified them about Resident #1's sacral pressure ulcer on 12/27/2025. They were not able to assess an area if notified, but they could observe an area and notify a Registered Nurse and a medical provider. During a phone interview on 01/16/2026 at 2:20 PM Registered Nurse #12 stated they worked the night shift (12/26/2025 into 12/27/2025) and were called to assess a pressure area on Resident #1's sacrum by Certified Nurse Aide #14. They were not sure what time they assessed the area. The area was red, and quarter sized. They cleansed the area with normal saline, patted it dry and applied a foam dressing for protection. They thought about documenting a nursing progress note and notifying a medical provider, but they never did. They did not want to call a medical provider in the middle of the night about a pressure area, which is why they reported to the day nurse. When their shift was done, they could not remember who the nurse was they reported to. During an interview on 01/16/2026 at 3:30 PM with Registered Nurse Supervisor #13 (evening shift) they stated they were notified on 12/27/2025 by Licensed Practical Nurse #19 about Resident #1's high blood sugar and a pressure area on their sacrum. The resident's vital signs were within normal range. When they removed the foam dressing on the resident's sacrum it was foul-smelling with gray drainage. They called the on-call medical provider and received an order to send the resident to the Emergency Department for evaluation. During a phone interview on 01/23/2026 at 11:06 AM with the Director of Nursing they stated if a nurse discovered a skin issue on a resident, they should be notifying the nursing supervisor and medical provider, getting a medical order for treatment, and then starting the treatment order. If the nurse discovering a skin issue was a licensed practical nurse, they should contact a registered nurse for an assessment. If there was no registered nurse in the building, the nurse should be calling the Director of Nursing or Assistant Director of Nursing as identified on the nursing schedule as one of them would always be available. Registered Nurse #12 should have documented on Resident #1's pressure area then notified the medical provider for a treatment order and then started that treatment. Administration reviewed the policy for notification and re-educated the nurses on who to contact when a skin issue was found. 10 New York Codes, Rules and Regulations 415.12(c)(1)(2)

Based on record review and interview during the abbreviated survey (NY00370972, iQIES# 452008), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of three (3) residents (Resident #2) reviewed. Specifically, Resident #2 was discharged from the hospital to the facility with atrial fibrillation (irregular heartbeat) and a mechanical heart valve replacement and was ordered weekly Prothrombin Time/International Normalized Ratio's (blood test that checks how long it takes for blood to clot) and anticoagulant (blood thinner) therapy. There was no documentation in the resident's electronic record of a diagnosis of a mechanical heart valve replacement and no documented evidence of a provider rationale for the reason International Normalized Ratios were not maintained at the recommended levels for mechanical heart valves (2.5-3-5). Additionally, there was no documented evidence the resident's Prothrombin Time/International Normalized Ratio was obtained as ordered on 10/22/2024 and no documented evidence the provider was notified that it was not obtained. Three (3) days after the missed Prothrombin Time/International Normalized Ratio, the resident presented with impaired speech, was more confused and sent to the hospital where they were found with a subtherapeutic (blood level below desired treatment range) International Normalized Ratio (1.16) and they were diagnosed with an acute stroke. This resulted in actual harm that was not Immediate Jeopardy for Resident #2. Findings include: Findings include: The facility policy Coumadin (warfarin) Therapy and Monitoring, dated 10/2024 documented:-Anticoagulation was needed for stroke, atrial fibrillation, pulmonary embolism and mechanical heart valve replacements. Dosage: to achieve target International Normalized Ratio was usually 1.5 to 2.5 times control. Mechanical heart valve target International Normalized Ratio was usually higher at 2.5 -3.5. Care planning for residents on anticoagulant medication including reporting lab values as soon as they were received, monitoring side effects- International Normalized Ratio testing, observation, prevention of side effects-falls, identifying procedures where medication should be held, education and certified nurse aide plan. Nursing documented in the nursing progress notes and 24-hour report. -Residents on anticoagulant therapy i.e., Coumadin (generic name: warfarin), would be tracked using a red binder located on each unit, utilizing the Anticoagulant Therapy Flow Sheet to ensure appropriate care and treatment, as well as monitoring for side effects. Procedure: the licensed nurse (day/evening shift) initiated the Anticoagulant therapy flow sheet and placed Prothrombin Time/ International Normalized Ratio lab order on the laboratory log for the date ordered. The licensed nurse (night shift) reviewed laboratory log and completed the lab requisition form. The licensed nurse received and reviewed the laboratory report and called the physician to report lab results and obtain orders for Coumadin therapy. Resident #2 had diagnoses including atrial fibrillation and Parkinson's Disease. The 09/05/2024 Minimum Data Set assessment documented the resident's cognition was intact, they were dependent with most activities of daily living, and the resident took anticoagulant medications during the assessment period. The resident's Diagnosis Sheet and 09/05/2024 Minimum Data Set assessment did not document the resident had a mechanical heart valve replacement. The 08/30/2024 hospital discharge summary documented Resident #2 was admitted with syncope (temporary loss of consciousness), collapse, and urinary tract infection. The resident had history of atrial fibrillation (irregular heartbeat that could increase risk of stroke), mechanical aortic valve replacement (surgical procedure where aortic valve is replaced with an artificial valve, higher risk of blood clots) and supratherapeutic (blood level higher than desired treatment range) International Normalized Ratio (blood test that checks how long it takes for blood to clot). Discharge medications included warfarin (anticoagulant) 2 milligrams, alternating 1 milligram and 2 milligrams every night. The 09/03/2024 Physician Assistant #4 progress note documented the resident was seen following hospitalization for falls and a urinary tract infection. The resident's diagnoses and assessment included atrial fibrillation, continue on warfarin, and they would order International Normalized Ratio to assess further. The 09/19/2024 History and Physical completed by the Medical Director documented the resident was admitted following hospitalization. The resident's diagnoses included atrial fibrillation. The History and Physical did not address a mechanical heart valve. The 10/02/2024 former Physician Assistant #4 note documented a follow up for atrial fibrillation. The recent International Normalized Ratio was 3.3 and supratherapeutic. The plan was to reduce the dose and repeat International Normalized Ratio in one (1) week. There was no documentation related to the resident's mechanical heart valve. The 10/02/2024 physician order documented warfarin 1 milligram every other day. The 10/07/2024 Comprehensive Care Plan did not document the resident had atrial fibrillation or a mechanical heart valve and did not address a plan for monitoring the resident related to anticoagulation therapy. The 10/09/2024 former Physician Assistant #4 note documented a follow up for atrial fibrillation. The resident's recent International Normalized Ratio was 1.9 and was therapeutic. The resident would continue the current dose and recheck bloodwork in one (1) week. The 10/10/2024 physician order documented Prothrombin Time (measurement of blood clotting)/International Normalized Ratio weekly on Tuesdays. There was no documentation of a therapeutic range in the order. The 10/15/2024 Nurse Practitioner #5 documented the resident's International Normalized Ratio was 2.2 and was in therapeutic range. The plan was to continue the current dose and recheck blood work in one (1) week. There was no documented evidence the resident's Prothrombin Time/International Normalized Ratio was completed on 10/22/2024 as ordered every week. The 10/02/2024 to 10/23/2024 Medication Administration Record documented the resident was administered warfarin Sodium 1 milligram tablet every other day. On 10/23/2024, Physician Assistant #4 documented the resident was seen for high cholesterol. The note did not address the resident's Prothrombin Time/International Normalized Ratio that was scheduled to be drawn the previous day (10/22/2024). The 10/25/2024 at 9:01 AM Licensed Practical Nurse #6 note documented the (unnamed) medical provider was aware the resident's Prothrombin Time/International Normalized Ratio was not drawn that week. A new order was obtained to redraw on 10/29/2024 as the level (Prothrombin Time/International Normalized Ratio ) had been stable. The 10/25/2024 at 11:08 AM Assistant Director of Nursing #3 progress note documented Resident #2 had increased shaking in their hands and arms, they were unable to speak, and speech was unclear and minimal. The medical provider was notified. On 10/25/2024, Physician Assistant #4 documented the resident was seen for physical decline and not answering questions per their baseline. Family was present and requested to send the resident to the hospital. The 10/25/2024 hospital record documented the family reported Resident#2 was more confused and not as talkative and had a history of stroke. The resident's International Normalized Ratio was 1.16 and Computerized Tomography Scan (specialized x-ray) findings were concerning for acute to subacute infarct (stroke). Neurology reported the resident was found with aphasia (impaired speech from dysfunction of the brain), drowsiness and with acute/subacute left middle cerebral artery (supplies blood to large portion of the brain) infarct. The resident was outside the window for administration of thrombolytic therapy (treatment that dissolves blood clots). The resident had a mechanical heart valve was on warfarin but with the acute stroke and was at high risk of hemorrhage. The resident most likely had a stroke as evidenced by subtherapeutic (blood level below desired treatment range) International Normalized Ratio. During an interview on 08/19/2025 at 12:18 PM, Assistant Director of Nursing #3 stated nursing staff filled out the laboratory requisition prior to the lab coming on Tuesdays and Thursdays. Prothrombin Time/International Normalized Ratios were typically drawn on Tuesdays. If a resident's lab work was missed, they expected the medical provider to be notified immediately and follow the medical provider's order. Assistant Director of Nursing #3 confirmed Resident #2's record documented orders for weekly Prothrombin Time/International Normalized Ratio's. The resident had labs drawn on 10/22/2024; however, those labs did not include the Prothrombin Time/International Normalized Ratio and Assistant Director of Nursing #3 was not sure of the reason. They stated the medical provider should have been notified on 10/22/2024 the lab was missed. During an interview on 08/19/2025 at 12:55 PM, Physician Assistant #4 stated they became aware of a resident's diagnoses upon admission by reviewing the hospital paperwork or the diagnoses entered by the admission nurse. Warfarin was a blood thinner and used for blood clots or atrial fibrillation and was monitored by blood work. If a resident's Prothrombin Time/International Normalized Ratio was missed, they expected to be notified and they would either order labs to be done the next day or the next scheduled lab day. For a resident with diagnoses of both atrial fibrillation and a mechanical heart valve replacement, they expected the International Normalized Ratio to be maintained between 2.5-3.5. They were not sure of the reason Resident #2's diagnosis of mechanical heart valve was not in their progress notes or in the resident record. They stated if they knew the resident had a mechanical heart valve, they might have considered increasing the warfarin dose on 10/09/2024, provided the residents condition was relatively stable. However, they would have weighed the risks if the resident was a high fall risk. Physician Assistant #4 did not recall being notified on 10/22/2024 of the resident's missed International Normalized Ratio and expected to be notified. During an interview on 09/04/2025 at 12:54 PM, the Medical Director stated they became aware of a resident's diagnoses by reviewing the diagnoses sheet which was entered by nursing and by reviewing hospital records. For a resident with atrial fibrillation and a mechanical heart valve, they would want to see the International Normalized Ratio around 2.5-3. If they did not document the resident had a mechanical heart valve in their 09/19/2024 History and Physical, they probably were not aware of the diagnosis, as it was their consistent practice to enter all diagnoses in which they were aware. The diagnosis should have been on the resident's diagnoses sheet and in the care plan. On 10/09/2024, when the resident's International Normalized Ratio was 1.9, they may have increased the resident's warfarin depending on previous trends of International Normalized Ratio's. When the resident's International Normalized Ratio was not drawn on 10/22/2024, they should have been notified in order to determine the next steps to be implemented. On 10/25/2024, when the resident was sent to the hospital, the lack of timely International Normalized Ratio monitoring and failure to maintain the resident's International Normalized Ratio in the recommended range for a mechanical heart valve could have contributed to the resident's stroke. 10 NYCRR 415.12

Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 kitchen walk-in coolers. Specifically, the left walk-in cooler was not maintaining proper temperature. Findings include: The facility did not have a policy or procedure for preventative maintenance of the walk-in coolers. The facility policy, Food Storage, revised 7/2023, documented perishable food such as meat, poultry, fish, dairy products, fruits, vegetables, and frozen products must be frozen or stored in the refrigerator or freezer immediately after receipt to assure nutritive value and quality. Refrigeration temperatures should be thermostatically controlled to maintain food temperatures at or below 41 degrees Fahrenheit. All refrigerator units were kept clean and in good working condition at all times. Potentially hazardous food, or time/temperature control for safety food must be maintained at or below 41 degrees Fahrenheit unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures were maintained at or below 41 degrees Fahrenheit. During an interview on 1/14/25 at 11:03 AM, Food Service Director #26 stated coolers were checked every morning between 2:30 AM and 3:30 AM, and every evening between 7:30 PM and 8:30 PM. They stated they did not check the cooler temperature at any other times during the day. The facility's Refrigeration Temperature Record for the left walk-in cooler (log sheet labeled #2) documented the temperature was 36 at 3:30 AM on 1/14/2025. Staff could not identify the initials of the person who recorded the temperature. During an observation on 1/14/2025 at 10:46 AM, a small plastic 6-inch by 6-inch container labeled ground [NAME] and beans and dated 1/9 was located on the top shelf of the left walk-in cooler and was measured at 45 degrees Fahrenheit. On a lower shelf, a shallow plastic container of ham salad was measured at 47 degrees Fahrenheit; and pulled pork measured at 46 degrees Fahrenheit. The external thermometer on the walk-in cooler read 45 degrees Fahrenheit. A small white plastic thermometer just inside the cooler read 30 degrees Fahrenheit. During an observation and interview on 1/14/2025 at 1:00 PM, the contents of the left walk-in cooler were measured with Regional Food Service Director #18. The plastic 6-inch by 6-inch container of ground [NAME] and beans was measured at 45 degrees Fahrenheit, ham salad was measured at 47 degrees Fahrenheit, a one gallon jug of olives measured at 48 degrees Fahrenheit, a 5-pound block of ham measured at 46 degrees Fahrenheit, and left over pork chops were measured at 46 degrees Fahrenheit. A small white thermometer at the front of the cooler read 32 degrees Fahrenheit and the external thermometer read 45 degrees Fahrenheit. Regional Food Service Director #18 stated the cooler temperatures were checked daily. The morning staff had already left for the day, and they could not find anyone who knew how long some items were in the cooler. They stated they did not know how long the cooler was out of temperature. The following items were measured and discarded: items dated 1/15/2025: rice 51 degrees Fahrenheit; ground pork 46 degrees Fahrenheit; ground chicken 47 degrees Fahrenheit; 2 full hotel pans of pork 49 - 51 degrees Fahrenheit, 1 and a half hotel pans of turkey stew 52 degrees Fahrenheit, pureed chicken 54 degrees Fahrenheit; items dated 1/13: hot dogs (half hotel pan) 47 degrees Fahrenheit, pureed chicken 49 degrees Fahrenheit; beef stew 46 degrees Fahrenheit; ground chicken 47 degrees Fahrenheit; pureed pasta 46 degrees Fahrenheit; pureed tuna 46 degrees Fahrenheit; half deli ham - 46 degrees Fahrenheit; half deli turkey 47 degrees Fahrenheit; and 3 full hotel pans of beef stew 46 - 47 degrees Fahrenheit 47; and a pan of ground turkey dated 1/12 was measured at 50 degrees Fahrenheit. During an interview on 1/14/2025 at 1:07 PM, Dietary Aide #17 stated they checked and documented cooler temperatures occasionally as part of their routine duties. They stated for the left walk-in cooler, they used the small white thermometer just inside the cooler. They stated they were not sure what the required temperatures were and would have to look on the form posted beside the cooler. During an interview on 1/15/2025 at 3:13 PM, Regional Food Service Director #18 stated the cooler temperatures should have been 41 degrees and below. If something was out of temperature, the process was to notify the supervisor who checked the food, transferred the food within temperature to another location, and discarded food out of temperature. They stated staff checked the cooler by reading the thermometer and they did not measure the temperature of the contents to ensure the thermometer was correct. They stated it was important for foods to be properly stored to prevent the growth of bacteria that could cause foodborne illness. Bacteria could grow quickly resulting in residents becoming sick which was of great concern due to resident's underlying conditions and immune systems that might not be strong enough to fight off the bacteria. 10NYCRR 415.29

48446 Based on record review, observations, and interviews during the recertification survey conducted 1/13/2025-1/19/2025, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 5 resident units (Units 2 North, 2 South, and 3 South) reviewed. Specifically, Units 2 North, 2 South and 3 South had several walls with missing paint, patched up holes unpainted, resident room doors with missing thresholds where dirt/debris had collected, missing tiles, dirty linen on the resident room floors, and the 2 south dining room that was not decorated or homelike. Findings include: The facility policy, Resident Rights, revised 2/2022, documented the residents had rights to a dignified existence. The facility policy, Quality of Life- Homelike Environment, revised on 2/2022, documented the residents were provided a safe, clean and comfortable and homelike environment. The facility staff and management should to the extent possible, reflect a personalized homelike setting that included clean, sanitary, and orderly environment, inviting colors and decor. The undated facility Housekeeper/Room Attendant Job Description documented the housekeepers were responsible for the cleaning and sanitation of the facility daily. All housekeepers must report problems, concerns, and maintenance issues to the supervisor. Review of the facility work orders dated 11/1/2024 to 1/16/2025 there were multiple open work orders that had not been completed. The following were observations on 2 north unit: - On 1/13/2025 at 10:46 AM, room [ROOM NUMBER]-B, there was a large approximately 2 feet tall by 6 inches wide scraped missing painted area on the wall behind the head of bed. - On 1/16/2025 at 7:38 AM, room [ROOM NUMBER]- B, the wall to the right of the head of the bed there was an unpainted 10 x 10-inch spot of plaster. During an interview on 1/17/2025 at 9:36 AM, Registered Nurse Unit Manger #7 stated the staff should use the computer to enter a work order if they noticed something needed to be fixed. For a home-like environment, the walls in the residents' room should be maintained. They were not aware of any issues with the walls in rooms 265-B and 272-B. The following were observations on 2 South unit: - On 1/13/2025 at 10:29 AM, room [ROOM NUMBER], missing floor tiles near the bed and peeling paint around the bathroom sink. - On 1/13/2025 at 11:04 AM, room [ROOM NUMBER], the door threshold was missing and caused an uneven floor surface. - On 1/13/2025 at 12:55 PM, room [ROOM NUMBER] had several empty 2 liter bottles of soda on the floor and at the foot of the resident's bed. The door threshold was missing that caused an uneven floor surface and the area was discolored black and brown. - On 1/14/2025 at 8:46 AM, room [ROOM NUMBER] the door threshold was missing and caused an uneven floor surface. - On 1/14/2025 At 1:09 PM, room [ROOM NUMBER] had a bag of dirty linens on floor, there was a pizza box resting on the trash can, four 2 liter bottles of soda on the floor at the foot of the bed, and the doorway threshold was missing leaving a black and brown surface and uneven floor.- At 1:09 PM, room [ROOM NUMBER] had a bag of dirty linens on floor, there was a pizza box resting on the trash can, four 2-Liter bottles of soda on the floor at the foot of the bed, and the doorway threshold was missing leaving a black and brown surface and uneven floor. - On 1/14/2025 at 1:12 PM, room [ROOM NUMBER] had 3 bags of dirty linens under sink and towel on the floor saturated with yellow colored liquid. - On 1/14/2025 at 2:49 PM, room [ROOM NUMBER] had a grapefruit sized missing paint spot to the right of the door when opened, several areas of scuffed missing paint on the left wall entering the resident's room and a missing floor tile outside the door that was covered with brown debris. - On 1/15/2025 at 11:35 AM, room [ROOM NUMBER] had a sticky yellow fluid on the floor the size of a basketball at the bottom of the bed. - On 1/16/2025 at 10:32 AM, room [ROOM NUMBER] was missing portions of the door threshold causing an uneven floor surface. - On 1/16/2025 at 10:33 AM, room [ROOM NUMBER] was missing the threshold between the door and hallway. The area contained a black and brownish substance and caused an uneven floor surface; and there were 2 bags of dirty linen on the floor at the foot of the bed. - On 1/16/2025 at 10:40 AM, the dining room on 2 South had a hole in the wall near the floor, and the molding was discolored black. There was missing paint on the wall under the left side of the television and on the right side there was a white patched, unpainted area. Other than a blank chalk board and a clock, there were no homelike or personalized items. - On 1/16/2025 at 10:46 AM, room [ROOM NUMBER] had a missing threshold and the area on the floor was discolored and uneven, and on the left side of the wall when entering the room, there was a patched-up section of wall with missing paint. During an interview on 1/16/2025 at 10:47 AM, Certified Nurse Aide #1 stated when something on the unit was broken, they were supposed to put in a work order on the computer and it would go to the appropriate department. They confirmed the threshold in room [ROOM NUMBER] was mostly missing and the area was brown. They stated they would notify maintenance because it was a tripping hazard. They confirmed there was also missing paint in the same room. The one bigger spot was from when there was a hole in the wall that was patched up and it was not repainted. The holes and missing paint were not homelike. They stated the bags of dirty linen should not be left on the floor as it was an infection control issue, and it was not homelike. They were not sure why the walls at the end of the hallway were painted different colors. They stated room [ROOM NUMBER] was missing most of the threshold and was discolored and this was a tripping hazards, they always catch their own shoe on it. During an interview on 1/16/2025 at 10:58 AM, Housekeeper #2 stated they were responsible for cleaning rooms, bathrooms, nurses' station, and dining room and shower rooms. They stated if they saw something broken, they would remove and replace it. If there was something they could not fix they would put in a work order, and which went directly to maintenance. Maintenance was responsible for replacing thresholds in the doorways. Missing thresholds would be a tripping hazard. They stated they have seen dirty linen on the floor in resident rooms. The certified nurse aides were responsible to place dirty linen in the dirty room. Dirty linens and uneven floors were not homelike. The following observations on were made on 3 south: - On 1/15/2025 at 3:27 PM, the door across from the nurses' station was missing the molding on the doorknob side, and the door behind the nurses' station had a large scrape across the middle of the door. - On 1/16/2025 at 10:18 AM, the door jam and framing around room [ROOM NUMBER] had several spots of palm sized chipped and peeling paint. - On 1/17/25 at 8:41 AM, on 3 south room [ROOM NUMBER], the door jam and framing had several palm sized areas of chipped and peeling paint remained. At 8:42 AM, there was a door across from the 3 south nurses station missing molding on the doorknob side and the door behind the nurses' station had a large scrape across the middle. At 8:43 AM, the clean linen room door was still missing paint across middle of door between molding. During an interview on 1/17/2025 at 8:44 AM, License Practical Nurse Unit Manager #5 stated if they noticed an environmental issue they would complete a work order. Typically, the issue was fixed the same day. Any staff member could fill out a work order. They had not noticed the molding across from nurses' station or clean linen door missing paint. It was not homelike for the residents. During an interview on 1/17/2025 at 8:49 AM, Certified Nurse Aide #6 stated if they noticed a maintenance issue, they would notify the charge nurse or fill out a work order. They had not noticed the missing paint or the missing molding. They stated it was an eyesore and not homelike for the residents. During an interview on 1/16/25 at 1:18 PM, the Director of Housekeeping and Laundry stated every day one of the residents' room were assigned to be deep cleaned and then documented on the calendar. Dirty linen should be brought to the soiled room. Some of the housekeepers do not know how to the use the work order system so they would leave a handwritten note. During rounds they have noticed many thresholds were missing. They do not think anyone understood the thresholds need to be reported to maintenance to replace. A missing threshold would cause the floor to be uneven which would cause a tripping hazard. Missing sections of a tile should also be reported. Any staff member could fill out a work order. During an interview on 1/16/2025 at 1:42 PM, the Director of Maintenance stated they had a computerized work order system, and all staff were trained on how to complete a work order. They stated once they get a work order it depends on the work for how long it would take to fix. For example, broken faucets were fixed in 24 hours or when they get the part, ceiling tiles were fixed in 24 hours and floors that needed to be fixed may take 2-3 days. Most of the work orders were completed in 24 hours. There were 3 or 4 rooms that needed to be painted. They did not have any outstanding work orders for missing thresholds. If the threshold was missing it could be a tripping hazard. 10 NYCRR 415.29(j)(1) 48895

Based on observations, record review, and interview during the recertification and abbreviated (NY00322139) surveys conducted 1/13/2025-1/17/2025, the facility did not ensure prompt efforts were made to resolve grievances for 9 of 9 anonymous residents and 1 additional resident (Resident #446) reviewed. Specifically, 9 of 9 residents during the resident group meeting stated they did not know who the grievance official was or how to file a grievance. Long call bell wait times were a recurrent complaint in the monthly resident council meetings and Resident #446 had filed a grievance regarding long call bell wait times. Findings include: The facility policy, Grievance/ Complaint Procedure, reviewed 11/2023 documented the facility provided residents the means and assistance to file a grievance or complaint concerning their treatment. The Director of Social Services served as the facility's grievance official. The facility policy, Call Bell, reviewed 3/2024 documented call bells were answered promptly by all employees. The facility policy, Resident Rights, reviewed 3/2024 documented residents had the right to voice grievances and have the facility respond to those grievances. During a resident group meeting on 1/13/2025 at 2:03 PM, 9 anonymous residents stated the Director of Activities was present during monthly resident council meetings and recorded the group's concerns. They were not sure if the facility had an official grievance officer or who that person was. They had never filed a formal grievance and were not sure of the process. Long call bell wait times were an ongoing problem they voiced at the monthly meetings and continued to be an issue. Certified nurse aides were taking breaks together leaving minimal staff on the floor to answer the call bells. The resident council meeting notes documented call bell timeliness concerns were included in the 7/17/2024, 8/21/2024, 9/18/2024, 10/16/2024, and 11/27/2024 meetings. The Director of Social Services and the Director of Activities were listed as staff in attendance for the August 2024- November 2024 meetings. The grievance log from August 2024-January 2025 documented a formal grievance was filed for call bell timeliness on 1/11/2025 by Resident #446. From 1/13/2025-1/17/2025, there was no posted information observed in the facility related to the facility grievance officer, contact information, or accessible grievance forms. The following call bell observations were made: - On 1/13/2025 at 12:22 PM, the call light in room [ROOM NUMBER] went off. At 12:35 PM an unidentified staff member entered and exited the room, and the call bell continued to go off. At 12:35 PM, the Registered Nurse Unit Manager #7, looked down the hallway with the active call bell and went into their office. At 12:36 PM, an unidentified staff walked past room [ROOM NUMBER] with the call bell still activated. At 12:39 PM, the call bell was answered. - On 1/13/2025 at 12:31 PM, the 3-tone alarm panel displayed room [ROOM NUMBER]'s call bell had been going off for 43 minutes. - On 1/14/2025 at 8:21 AM, the 3-tone alarm panel displayed room [ROOM NUMBER]'s call bell had been going off for 28 minutes. An unidentified licensed practical nurse was standing at the nurse's station desk and an unidentified staff was in the office labeled unit manager across from the alarm panel display and 2 unidentified staff members were talking in the secretary's office behind the nurse's station. - On 1/14/2025 at 2:36 PM, the call bell was initiated in room [ROOM NUMBER]. At 3:03 PM, the call bell was answered. - On 1/15/2025 at 9:20 AM, the 3-tone alarm panel displayed room [ROOM NUMBER]'s call bell had been going off for 45 minutes. During an interview on 1/17/2025 at 9:12 AM, the Director of Activities stated they attended all resident council meetings and long call bell times were a recurrent monthly complaint and had been as long as they had been employed at the facility. These concerns went to the Administrator and the Director of Nursing. It was important call bells were answered timely because it meant the resident needed something and staff was there to take care of the residents' needs. During an interview on 1/17/2025 at 9:35 AM, the Director of Social Services stated they were the official grievance officer. There were frequent complaints of long call bell wait times on all units. Long call bell times were investigated through the formal grievance process. The nurse managers investigated what staff were working on during the call bell complaint and education was provided. They were aware of certified nurse aides going on breaks together, but they should not be unless they were on separate units. It was important call bells were answered timely for resident safety and care. It was important grievances were responded to timely, so the residents felt heard and that they were taken seriously. During an interview on 1/17/2025 at 9:46 AM, the Director of Nursing stated long call bell wait times were a frequent grievance. In-services were completed and staff assignments were changed. The goal was as nursing management strengthened; long call bell times could be corrected. This was a global issue, and all staff were responsible to answer the call bells. They had not yet found a solution that worked to correct long call bell wait times but was working on it. It was important call bells were answered timely because the resident needed attention in that moment. 10NYCRR 415.13(C)(1)(ii)

Based on observation, record review, and interview during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional standards for expiration dates for 2 of 5 medication carts (3 North A side and 2 North A side carts) and 1 of 3 medication storage rooms (3 North) reviewed, and 1 medication cart (3 south B side cart) was observed unlocked and unattended. Specifically, the 3 North A Side cart had eye drops, multidose diabetic pens (device used to deliver injectable medication), a multidose insulin vial, and inhalers without opened or discard dates; the 2 North A side cart had multidose diabetic pens without opened dates or discard dates, and a multidose diabetic pen without a resident identifier or an opened or discard date; the 3 North medication refrigerator contained a multidose influenza vaccine vial and a multidose tuberculin vial that were expired; and an additional multidose influenza vaccine vial that did not have an opened date or discard date. Additionally, the 3 South B side cart was observed unlocked and unattended in the common resident hallway. Findings include: The facility policy, Storage of Medications revised 8/2024 documented medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations. The medication supply was accessible only to the licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies were locked when they were not attended by persons with authorized access. Outdated medications were immediately removed from inventory, disposed of, and reordered from the pharmacy. Certain medications such as multiple dose injectable vials and ophthalmic (eye) medications required an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. The nurse placed a date opened sticker on the medication and recorded the dated opened and the new date of expiration. The expiration date of the vial or container was 30 days from opening unless the manufacturer recommended another date. The nurse checked the expiration date of each medication before administering it. Expired medications were not administered. During an observation on 1/14/2024 at 8:35 AM, the 3 North A side medication cart was observed with Licensed Practical Nurse #24. Resident #43 had opened ciprofloxacin (antibiotic) 0.3% eye drops without an opened or expiration/ discard date; Resident #45 had an opened Ozempic (GLP-1 agonist) multidose pen and 2 opened Trelegy Ellipta inhalers (treats chronic lung disease) without an opened or expiration/ discard date; Resident #59 had an opened Lantus (insulin) multidose pen, an opened Humalog (insulin) multidose vial, and a Trelegy Ellipta inhaler without opened or expiration/ discard dates; Resident #111 had an opened Lantus multidose pen and 2 opened Anoro Ellipta inhalers without opened or expiration/ discard dates; and Resident #125 had opened prednisolone (steroid) 1% eye drops and ketorolac (treats irritation) 0.5% eye drops without opened or expired/ discard dates. Licensed Practical Nurse #24 stated without opened dates, they would not know if a medication was good. The nurse that opened the medications was responsible they were dated. Nurses were also responsible to look at the medication dates prior to administration. Insulin was good for 30 days and the eye drops, and the inhalers should also follow the 30 day expiration rule. If expired medications were given, they were not as effective. They did not think they had given any of the undated medications this morning. During an observation on 1/14/2025 at 8:54 AM, the 3 North Medication Storage room was observed with Licensed Practical Nurse #25. The refrigerator contained an opened box with a multidose vial of influenza vaccines with a date on the box of 11/2024 and an opened box of tuberculin skin test multidose vial with a date on the box of 11/2024. There was also an opened box with a multidose vial of influenza vaccines that did not have an opened or expiration/ discard date. Licensed Practical Nurse #24 stated these vials were good for 30 days and if they were not dated it would not be known if they were any good. During an interview on 1/14/2025 at 9:04 AM, Registered Nurse Unit Manager #9 stated all multidose medications were labeled when opened so the nurses knew how long they were good for. The date was checked by the nurse before administering medications to make sure they were not expired. Expired medications could be less effective or there could be adverse reactions. They did audits of the medication carts weekly and ensured medications were dated and not expired. There was a document from the pharmacy the nurses checked if they were unsure how long a medication was good for. Insulins, eye drops, and inhalers all had expiration dates. During an observation on 1/14/2025 at 9:06 AM, the 2 South A side medication cart was observed with Licensed Practical Nurse #21. Resident #76 had an opened Basaglar (insulin) multidose pen without an opened or expiration/ discard date; Resident #163 had an opened Humalog (insulin) multidose pen without an opened or expiration/ discard date; and there was a Trulicity multidose pen without resident identifiers or an opened or expiration/ discard date. Licensed Practical Nurse #21 stated without opened dates, there was no way of knowing when the medications expired. Expired medications were not as effective, and residents could have higher blood sugars if they received these expired mediations. Insulins were good for 40 days. During an interview on 1/16/2025 at 3:53 PM, Registered Nurse Unit Manager #22 stated medications were labeled when they were opened so the nurses knew how long they were good for. If a medication was not dated it needed to be thrown out because they would not know if the medication was still good. Insulin was good for 28 days and if it was expired, it may not effectively manage blood sugar. During an observation on 1/17/2025 at 8:44 AM, the 3 South B side medication cart was unlocked and unattended in the hallway. Licensed Practical Nurse Unit Manager #5 stated they just stepped away for a moment to put their coffee in the office. They stated residents and other staff should not have access to their medication cart. During an interview on 1/17/2025 at 9:46 AM, the Director of Nursing stated insulins should have been dated when opened or the nurse could not guarantee the effectiveness of the medication and that it was not expired. All medications were only guaranteed effective for certain time. The nurse that opened the medication was responsible it was dated. The night shift was supposed to check the carts and removed items that were expired or not dated as opened. No medications should be administered without an opened date. Expired medications were no longer in their intended form. Medication carts should be locked when not attended. The expectation was nurses hit the lock button on the cart any time they walked away from it. 10NYCRR 415.18(d)

Based on observation and interview during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals (the 1/14/2025 1st floor lunch meal and the 1/15/2025 3rd floor lunch meal) reviewed. Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meals on 1/14/2025 and 1/15/20254. Additionally, 9 of 9 anonymous residents present at the Resident Council meeting and Resident #103 stated the food was not appetizing. Findings include: The 1/2022 updated facility policy, Food Temperatures, documented all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Temperatures should be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the portioning, transporting, and delivery process until received by the individual recipient. During an interview on 1/13/2025 at 12:39 PM, Resident #103 stated the food was not hot and was not palatable. During a resident group interview on 1/13/2025 at 2:30 PM, 9 anonymous residents stated the food was not hot and was lukewarm. Their concerns included burnt grilled cheese sandwiches, the meat was tough, noodles were overcooked, and there was not enough variety with ham every week. The cold foods were not served cold. During a 1st floor lunch meal observation on 1/14/2025 at 12:13 PM Resident #7 was served their lunch meal tray and used as a test ray. The resident refused a replacement meal, as they had ordered food from outside the facility. The ham was measured at 121.1 degrees Fahrenheit, the corn was 113.9 degrees Fahrenheit, and the orange juice was 52 degrees Fahrenheit. The food temperatures were verified by Licensed Practical Nurse #12. The ham was very dried out, with a jerky like appearance, and the corn was tough with a plastic texture to the casing. During an interview on 1/15/2025 at 8:19 AM, Certified Nurse Aide #13 stated that residents complained about the food, and some would order out instead of eating the facility food. During a 3rd floor lunch meal observation on 1/15/2025 at 12:39 PM Resident #173 was served their lunch meal tray. A replacement tray was ordered, and Resident #173's original meal tray was tested . The tuna noodle casserole was measure at 133 degrees Fahrenheit, the cooked carrots were 110.8 degrees Fahrenheit, the mashed potatoes were 126.9 degrees Fahrenheit, and the gravy was 128.5 degrees Fahrenheit. The food temperatures were verified by Certified Nurse Aide #14. During an interview on 1/17/2025 at 9:12 AM, the Director of Activities stated there were recurrent food complaints during the Resident Council meetings. The complaints included cold food, not getting the food they wanted, and waiting too long for their called down second-choice meal to arrive. The Director of Activities stated residents should enjoy their food. If they did not eat it could lead to weight loss, skin problems, and poor quality of life. During an interview on 1/17/2025 at 9:42 AM, Dietary Aide #17 stated hot food should be served at a temperature higher than 140 degrees Fahrenheit, and cold food should be served under 40 degrees Fahrenheit. The temperatures of the tuna noodle casserole, carrots, mashed potatoes, gravy, ham, and the corn were too cold. The orange juice was too warm for a cold beverage. Food should be palatable and served at appropriate temperatures. It should look appetizing as we eat with our eyes first. If it did not look good to the kitchen staff, it would not look good to the residents. It was important for residents to enjoy their food for proper nutrition and healing purposes. During an interview on 1/17/2025 at 10:02 AM, the Corporate Regional Director stated hot food should be served at 135 degrees Fahrenheit or higher, and cold food should be 41 degrees Fahrenheit or below to remain out of the danger zone. Residents should have palatable and enjoyable food. It was important to serve the residents food at appropriate temperatures because bacteria could grow in the danger zone between 41 degrees Fahrenheit and 135 degrees Fahrenheit and could make them sick. The tuna noodle casserole, cooked carrots, mashed potatoes, gravy, ham, and corn temperatures were not acceptable. 10NYCRR 415.14(d)(1)(2) 49448 51469

Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, food stored in the walk-in freezer was not protected, kitchen lighting was not properly shielded, and there were multiple unclean and uncleanable surfaces. Findings include: The facility policy, Food Storage, last reviewed 7/2023 documented: - food was stored in an area that was clean, dry, and free from contaminants. - all foods should be covered, labeled, and dated. - all refrigerator units were always kept clean and in good working condition. - all freezer units were always kept clean and in good working condition. The light bulb specifications provided by the facility did not document the bulbs were coated or shatter resistant. The following observations were made in the main kitchen: - on 1/14/2025 at 10:47 AM, there was an uncovered open box of hamburgers, an open junction box with exposed wiring, ice build-up on the ceiling, and food and packaging debris under shelving in the walk-in freezer. - on 1/14/2025 at 10:53 AM, the majority of the lights in the kitchen were not protected. - on 1/14/2025 at 11:26 AM, the condenser outside of the cooler had dirt and grease build-up. - on 1/14/2025 at 12:47 PM, the cove molding tiling was in disrepair beneath the two-bay sink. - on 1/14/2025 at 1:49 PM, there were several broken floor tiles under the three-door freezer in the dry storage room. During an interview on 1/15/2025 at 3:13 PM, Regional Food Service Director #18 stated it was important to have foods properly stored in the coolers to prevent contamination from something spilling into the food and fans blowing material into the food products. Floors should have been swept during the day and mopped at night. The stock person was responsible for cleaning the walk-in coolers. The walk-in freezer should have been cleaned weekly. There should not be packaging or food debris under the shelving. Broken floor tiles were not smooth and not easily cleanable. They stated it was important floors and equipment were kept clean to prevent cross-contamination, bacteria transmission, and pest control. Cleaning of the kitchen should be documented on the sanitation logs and periodic audits were conducted. The Kitchen Cleaning log audit for 12/2024 and 1/2025 was blank without entries. During an interview on 1/15/2025 at 3:36 PM, Kitchen Supervisor #27 stated they were not sure how long exactly the light covers had been missing from the kitchen, but they had been missing for several years. They were also not sure if the bulbs were shatter resistant. They stated it was important lights in the kitchen were protected to prevent light bulb fragments and other foreign objects such as insects and dust from falling into food. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 1/13/2025-1/17/2025, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #17) reviewed and 1 of 5 medications rooms (2 South B). Specifically, Resident #17's urinary drainage collection bag was not stored in a manner to prevent contamination and was observed lying directly on the floor, and the 2 South B side medication room sink was not functional. Findings include: The facility policy, Infection Prevention and Control, revised 5/2024, documented to prevent the spread of disease, handwashing was encouraged. The facility policy, Urinary Catheter Care, revised 5/2024, documented catheter tubing and drainage bags were kept off the floor. 1) Resident #17 had diagnoses including urinary retention (difficulty emptying the bladder), obstructive and reflux uropathy (blockage of urine flow), urinary tract infections, and extended spectrum beta lactamase resistance (an enzyme that makes bacteria resistant to some antibiotics). The 10/25/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, had an indwelling urinary, and had multidrug-resistant organisms. The 7/1/2024 Nurse Practitioner #20 medical order documented the resident was to have a 16-inch French (size of the catheter) urinary catheter for obstructive uropathy. The Comprehensive Care Plan dated 11/1/2024 documented Resident #17 had an alteration in bladder elimination related to obstructive uropathy. Interventions included a urinary catheter, the urinary drainage bag should be covered with a dignity bag and kept below the bladder and observe for signs and symptoms of urinary tract infections. During observations on 1/14/2025 at 1:22 PM and 2:56 PM, Resident #17's urinary catheter drainage bag was laying under the bed directly on the floor without a barrier. During an interview on 1/15/2025 at 8:19 AM, Certified Nurse Aide #13 stated they cared for Resident #17 a few times that week during the day shift. They received catheter training when they were hired, and it was important to keep drainage bags off the floor for infection control reasons. The floor was dirty, and Resident #17 could develop a urinary tract infection. During an interview on 1/15/2025 at 8:51 AM, Licensed Practical Nurse #21 stated certified nurse aides and nurses were responsible for catheter care. The drainage bag should never touch the floor and should always be in a dignity bag. If the drainage bag was on the floor, it should be sanitized and switched out for a new one. They stated floors were dirty with bacteria, which could cause Resident #17 to develop a urinary tract infection. During an interview on 1/16/2025 at 3:53 PM, Registered Nurse Unit Manager #22 stated nursing staff received training on catheters when hired. Urinary drainage bags were to be hung on the wheelchair or bedframe, so they did not touch the floor. If the drainage bag was on the floor, they expected nursing staff to pick it up off the floor immediately and clean the bag or change it out for a new one. They stated it was important for Resident #17's drainage bags to be kept off the floor because floors were dirty, and it could put the resident at risk for an infection. During an interview on 1/17/2025 at 9:20 AM, Infection Preventionist #23 stated urinary drainage bags should be kept below the resident's waist, in a blue dignity bag, and should not rest on the floor. The floor was dirty, the bag could become contaminated and lead to a urinary tract infection. 2) During an observation and interview on 1/15/2025 at 8:51 AM, the sink in the 2 South B side medication room had a white substance on both handles, rust on the right side of the handle, towels in the sink, and a basin over the towels on each side of the sink. The water was not able to be turned on. Licensed Practical Nurse #21 stated they notified maintenance months ago there was a problem with the sink. They shut the water off and there was no longer running water in the medication room. If you wanted to wash your hands you went to the nearest bathroom. They carried their own hand sanitizer in their pocket because proper hand hygiene was the number one way to prevent an infection. Facility Work Orders dated November 2024 to January 2025 documented: - on 12/2/2024 a work order was placed for the 2 South Nurse's Station sink for flooding and a broken sink. The work order was closed on 12/4/2024, it was a repeat work order, and there was a temporary fix in place completed by Maintenance Technician #25. - on 12/6/2024 a work order was placed for the 2 South Nurse's Station medication room leaking sink. It was closed on 12/10/2024. There were no visible leaks, and everything was dry, and the lines were checked. Maintenance Technician #25 spoke with the nurses. During an interview on 1/16/2025 at 1:42 PM, Maintenance Director #4 stated their department was responsible for maintaining rooms in the facility. When they received a work order, they looked at the problem, ordered parts if necessary, and fixed any issues, most of them within 24 hours. Faucets were fixed in 24 hours as it was important for staff and residents to have running water to wash their hands. They had not been in the medication room on 2 South B side recently. Maintenance Director #4 observed the sink, and stated there was a significant buildup of calcium along with rust. They were not sure why the sink was turned off. There should be a functioning sink in the medication room to wash hands. During an interview on 1/16/2025 at 3:53 PM, Registered Nurse Unit Manager #22 stated hand washing was the best way to prevent an infection and there was not a functioning sink in the 2 South B side medication room since at least September. They had completed a work order, and it remained broken. Staff could use the sink in the dining room to wash their hands. During an interview on 1/17/2025 at 9:20 AM, Infection Preventionist #23 stated handwashing was the primary way to prevent the spread of infections. They were not aware there was a sink that was not functioning in the medication room of 2 South B side. All sinks should be in working order. 10 NYCRR 415.19

Based on observations, record review, and interviews during the recertification and abbreviated (NY0035593 and NY00322139) surveys conducted 1/13/2025-1/17/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 1 resident (Resident #119) reviewed. Specifically, Resident #119 was not provided oral care as planned. Findings include: The facility policy, Activities of Daily Living Support, revised 1/2025, documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The facility policy, Mouth Care, dated 1/2022, documented residents' lips and oral tissues were kept moist, and the mouth should be cleansed and freshened to prevent oral infection. The equipment and supplies necessary included toothpaste, emesis basin, and applicators or gauze sponges. Resident #119 had a diagnosis including Parkinson's Disease (a progressive neurological disorder), stroke, and tremors. The 11/8/2024 Minimum Data Set Assessment documented that the resident was cognitively intact, did not reject care, and required substantial/maximal assistance with oral hygiene. The 12/20/2024 Comprehensive Care Plan for activities of daily living documented that the resident required substantial/maximum assistance for oral hygiene. Intervention included a helper was needed to perform more than half of the oral hygiene for the resident, the resident had their own teeth, and observe the mouth for sores, gum irritation, and any complaint of tooth pain. During an interview and observation on 1/13/2025 at 1:21 PM the resident had a thick white substance on their mouth and tongue. The resident stated their teeth were not brushed at all that day or the day before. They stated, historically when they had the ability to care for their own mouth, it was done 2-3 times a day. The resident stated the aides were busy and did not get time to clean their mouth every day. During an interviews and observations on 1/14/2025 at 1:43 PM the resident was in bed and stated oral care was not done and they had a very dry mouth. The resident's mouth appeared dry. At 3:45 PM the resident stated they had not received oral care. The resident's tongue and lips were dry. During an interview and observation on 1/15/2025 at 10:02 AM Certified Nurse Aide # 8 provided care to Resident #119. Certified Nurse Aide # 8 completed the bed bath and incontinence care, dressed the resident in a clean gown, gave the resident their call bell and exited the room. Certified Nurse Aide # 8 stated the care for the resident was complete and they did not offer oral care. Oral care should have been offered and provided but was missed in error. They stated it was important to maintain excellent oral care for the resident to maintain cleanliness and to check for sores in resident's mouth. During an interview on 1/16/25 at 9:00 AM Licensed Practical Nurse Unit Manager #5 stated the resident should have oral care done morning and night. It was important to maintain optimal oral care as it was essential to the resident's hygiene and just to feel good. Licensed Practical Nurse Unit Manager #5 stated the resident was on thickened liquids and their mouth had thick secretions as a result. The resident was also on a blood thinner, and they used the green sponge swabs to clean their mouth to avoid bleeding. Licensed Practical Nurse Unit Manager #5 was unaware that oral care was not provided for Resident #119. During an interview on 1/16/2025 at 2:00 PM Registered Nurse Unit Manager #9 stated they expected oral care to be done minimally in the morning and in the evening by the certified nurse aides and documented in the electronic medical record. Oral care was documented as not being done for the resident on 1/13/2025, 1/14/1025, and 1/15/2025 during the day shifts. 10 NYCRR 412.12(A)(3)

Based on observation, record review, and interview during the recertification survey conducted 1/11/23-1/19/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 7 isolated resident areas (resident rooms 224, 250, 262, 272, and 319, the third floor hall near the nursing station, and the second floor common area); and 2 pieces of resident equipment (Residents #27's and 47's wheelchairs). Specifically, the third floor hall, and Resident rooms 224, 250, 262, 272, and 319 had walls in disrepair, the second floor common area had three stained ceiling tiles, and the wheelchairs for Residents #27 and 47 had damaged/torn arms. Findings include: The housekeeping department Wheelchair and Equipment Cleaning Logs had been completed for the last two months. The log included the areas of the facility that was cleaned, the date it was completed, and the name of the person who completed the task. WHEELCHAIRS The following observations were made: - on 1/11/23 at 11:06 AM and 1:01 PM, both armrests on Resident #25's wheelchair had broken and cracked vinyl coverings with padding showing. - on 1/11/23 at 11:14 AM and 1:01 PM, and on 1/12/23 at 8:43 AM both armrests on Resident #47's wheelchair had missing sections and damaged sections of vinyl with padding showing. - on 1/12/23 at 8:43 AM, both armrests on Resident #47's wheelchair had missing sections and damaged sections of vinyl with padding showing. - on 1/12/23 at 9:08 AM, both armrests on Resident #25's wheelchair had broken and cracked vinyl coverings with padding showing, and a section of the frame above the foot pedals was unclean and soiled with a dried pink substance, dirt, and dust. - on 1/13/23 at 1:20 PM, both armrests on Resident #25's wheelchair had broken and cracked vinyl coverings with padding showing, and parts of the wheelchair were unclean with debris. - on 1/18/23 at 10:37 AM, both armrests on Resident #47's wheelchair had missing sections and damaged sections of vinyl with padding showing. During an interview on 1/12/23 at 2:39 PM, housekeeper #47 stated that wheelchairs were usually cleaned weekly, and there was a wheelchair cleaning list. During an interview on 1/12/23 at 2:45 PM, the Housekeeping Director stated that Resident #27's wheelchair had been deep cleaned monthly on 11/17/22 and 12/22/22. They stated that the resident would eat in the chair, and the chair was cleaned monthly and as needed. During an interview on 1/18/23 at 1:50 PM, the Maintenance Director stated all staff should notice details like damaged/worn armchairs and work orders completed. They stated that if a work order was placed for the wheelchair arms the maintenance department would replace the damaged parts. There was no scheduled maintenance for the wheelchairs by the maintenance department. During an interview on 1/18/23 at 2:44 PM, the Director of Therapy stated the therapy department issued wheelchairs to residents and would deliver the wheelchair to the resident's room. They stated the wheelchairs issued to the residents would be reviewed during the quarterly screening of residents. The Director stated if staff identified a wheelchair in disrepair, they should send a work order via the electronic work order system. They stated that if the vinyl on the wheelchair arms were worn, the pad was worn, or the seat was worn, a work order should be sent to the maintenance department. The Director stated the wheelchair part would be replaced and if the part was unserviceable the wheelchair would be taken out of service and another wheelchair would be provided to the resident. They stated that the therapy department only had extra leg rests. Resident #47's last quarterly screening was on 11/30/22, there were no wheelchair issues identified, and it was not acceptable if more than half of the armrest was missing. They stated there was no work order entered to replace Resident #47's wheelchair arms. The Director stated that damaged wheelchair arms could cause skin tears and other skin issues and were a dignity issue if the vinyl was missing. During an interview on 1/18/23 at 3:06 PM, certified nursing assistant (CNA) #49 stated they were assigned to Resident #47 until the resident was moved about 3 weeks ago. They CNA stated they had never cleaned the resident's wheelchair. If they saw a mess, they would clean the wheelchair. CNA #49 stated that they were not sure who was responsible for cleaning wheelchairs and would report disrepair of wheelchairs to the maintenance department. The CNA stated they had not paid any attention to the wheelchairs. They stated they had submitted work orders in the past and it sometimes took the maintenance department a couple of days to repair the wheelchairs. During an interview on 1/19/23 at 10:06 AM, licensed practical nurse (LPN) #50 stated that work orders were submitted by the computer and that all unit staff could submit a work order. They stated that the wheelchair arm rests should be entirely covered in black vinyl, cleaned when dirty, and staff should submit work orders immediately so maintenance could fix broken wheelchairs timely. LPN #50 stated they were not sure if staff was regularly checking the condition of wheelchairs and did not know if there was a routine schedule for cleaning. They stated that they had not looked at Resident #47's wheelchair since they resident changed rooms and would expect unit staff to let the nurse know or submit a maintenance work order if the arm rests were in poor condition. LPN #50 observed Resident #47's wheelchair and stated the chair arms were in disrepair and should have been fixed. The LPN stated they thought the arms had been that way for a while. The resident had showers on the evening and the wheelchair should have been noticed at that time. LPN #50 stated that the condition of the current arm rests could potentially cause skin issues by scraping the skin or irritating the skin. During an interview on 1/19/23 at 10:58 AM, registered nurse (RN) Unit Manager #11 stated that resident wheelchairs were supposed to be clean and in good repair. They stated that if a wheelchair was found to be unclean or broken, it should be cleaned and a work order for any issues would be created. RN Unit Manager #11 stated that the maintenance department would fix and or replace damaged parts. They were not sure what spare parts were kept onsite and would expect the arms of the wheelchair to be fixed. They stated that missing vinyl on the wheelchair arms could cause skin irritation or scratches, and it was also a dignity issue for the resident. RN Unit Manager #11 stated the night shift would clean the wheelchairs as needed, and that they were not sure if there was a set schedule for cleaning. They stated they were not sure if there were any audits on wheelchair condition, but unit staff should be mindful and submit a work order if needed. WALLS/CEILINGS The following observations were made: - on 1/11/23 at 2:25 PM, resident room [ROOM NUMBER] had a damaged/scuffed wall with a damaged outlet cover. - on 1/11/23 at 2:52 PM, resident room [ROOM NUMBER] had a wall based call bell unit that was not attached to the wall, dangling by the wires. - on 1/11/23 at 2:58 PM, the 2nd floor common area had 3 stained ceiling tiles. - on 1/11/23 at 3:08 PM, the wall behind the bed in resident room [ROOM NUMBER] was missing a section of cove base. - on 1/13/23 at 12:49 PM, the hallway wall near the third floor nursing station was missing a section of handrail. - on 1/13/23 at 1:03 PM, resident room [ROOM NUMBER] had a 6 foot section of missing cove base, and a wall by the sink was scrapped/damaged. - on 1/13/23 at 3:18 PM, the wall behind the bed in resident room [ROOM NUMBER] had a hole in it. Part of the bariatric bed had been pushed into the wall. During an interview on 1/18/23 at 10:40 AM, the Maintenance Director stated that they were not aware of the wall and ceiling issues identified or of the wheelchairs in disrepair. They stated the housekeeping department was responsible for wheelchair cleaning and nursing should have made the maintenance department aware of the damaged wheelchair armrests. The Maintenance Director stated that they were not aware of any active work orders for handrails. The Director stated it was not acceptable for parts of a bed to be located inside a damaged wall. They stated that they would round the facility monthly and during this rounding five random rooms would be checked. The Maintenance Director stated that all staff entering resident rooms and common areas knew how to create a work order for any issues they identified. 10 NYCRR 415.29(j)(1) 33421

Based on interviews during the recertification survey conducted 1/11/23-1/20/22, the facility failed to ensure the resident has the right to exercise their rights as a resident of the facility and as a citizen of the United States for all 145 residents of the facility. Specifically, mail from the United States Postal Service (USPS) was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Findings include: The undated facility Resident Orientation Handbook documented mail was to be distributed daily on each unit. If a resident had an outgoing letter, staff would assist in getting the mail to the Post Office During a resident group interview on 1/11/23 at 2:30 PM, seven anonymous residents in attendance stated personal mail was not delivered to them on Saturdays. Two residents stated the mail was received at the front desk, sent to the business office during the week for sorting during regular business hours, and Saturday's personal mail was not delivered to the residents. The residents stated Saturday mail would not be distributed until Monday or Tuesday. During an interview with the Business Office Manager on 1/17/23 at 9:32 AM, they stated the mail was received in the business office for sorting. Mail that was addressed to the facility would be set aside and residents' personal mail was given to the Activities Department to deliver to the residents. They stated they did not work weekends, but thought mail was delivered to residents because the Activities Department had staff that worked on Saturdays. During an interview on 1/17/23 at 9:45 AM with the Activities Director, they stated they were responsible for overseeing the residents' personal mail, and they and three additional activity staff members delivered personal mail to residents. If residents received personal mail on Saturdays, it was only in the form of packages from box store vendors. All personal mail coming from the USPS was placed in a white bin and tucked away safely until the Business Office Manager retrieved it on Monday morning for sorting and delivery to the residents. During an interview with certified nurse aide (CNA) #18 on 1/18/23 at 9:44 AM, they stated they sometimes worked at the front lobby desk. The mail was brought to the facility by a postal worker. The mail was in a white bin and was sent to the business office for distribution during the week. On Saturdays, the mail sat in a bin and waited until the business office opened on Mondays. Residents did not get personal mail delivered to them on Saturdays. During an interview with the Administrator on 1/18/23 at 2:30 PM, they stated mail came into the facility and was distributed from the front desk to the residents by the business office and activities staff. Residents should receive personal mail on the same days they would at their home. The front desk, business office and activities department were responsible for overseeing mail delivery. They were not aware residents did not receive personal mail on Saturdays. 10NYCRR 415.3(c)(l)(i)

Based on observations, record review and interview during the recertification and abbreviated surveys (NY00297359) conducted 1/11/23-1/20/23 the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported no later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury were reported to the New York State Department of Health (NYSDOH) for 1 of 3 residents reviewed (Resident #60). Specifically, Resident #60 was found with a blistered area on their abdomen and the injury was not reported timely to the NYSDOH as required. Findings include: The facility policy Abuse Prevention revised 2/2022 documented that reports of abuse, including injuries of unknown origin, were immediately and thoroughly investigated to rule out abuse. The facility would ensure injuries of unknown sources were reported to NYSDOH within 2 hours after the incident was discovered if serious bodily injury occurred or not later than 24 hours if the event did not involve abuse or serious bodily injury. Serious bodily injury was defined as extreme physical pain, substantial risk of death, loss or impairment of a bodily member/organ/mental faculty or requiring surgery/hospitalization /physical rehabilitation. Resident #60 had diagnoses including Parkinson's disease (a progressive neurological disease) and depression. The 6/7/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had physical behavioral symptoms directed towards others almost daily, required extensive assistance of 1 for bed mobility, supervision for eating, and had no active skin conditions. The 4/30/22 comprehensive care plan (CCP) documented the resident was at risk for bruising, had mood disturbances and delusions, and had ADL (activities of daily living) deficits. Interventions included gentle handling with care, monitor for pain/swelling and report changes. The resident received a regular consistency diet with thin liquids and staff were to ensure the resident was sitting upright for all meals, and staff were to open all containers and pour drinks into cups. The resident was independent with eating. A 6/8/22 RN #30 progress note documented at 4:00 PM, a CNA informed RN #30 the resident had skin tears on their abdomen, left hip, and left waist. The area was cleansed, a dressing applied, and the supervisor was notified. The 6/9/22 at 4:56 PM RN #31 progress note documented the resident had an abdominal wound with 2 blisters, the area was reported to be a scratch but later blistered, the wound was not witnessed but possibly caused by spilled hot coffee. An untimed 6/9/22 incident report completed by RN #31 documented the resident sustained a burn on their abdomen area on 6/8/22. The abdominal reddened area was 23 centimeters (cm) x 14 cm. Medical was notified on 6/9/22 at 2:15 PM and family was notified on 6/9/22 at 2:20 PM. An occupational therapy (OT) referral, up in dining room for all meals, and a sippy cup for all hot drinks were to be implemented. The 6/9/22 CNA #32 witness statement documented the CNA was called into the resident's room. The resident had blisters on their abdomen and 1 had opened. The CNA and another CNA got the nurse to look at the area. The 6/9/22 at 5:03 PM CNA #33 witness statement documented the CNA went to check on the resident and noticed burn marks on their stomach. The CNA then told the nurse. The 6/9/22 RN Supervisor #31 witness statement documented they were the supervisor on 6/8/22 and the unit floor nurse texted them that the resident had scratches. The RN Supervisor assessed the resident on 6/9/22. The resident had a reddened area 23 cm x 14 cm that contained 2 smaller open areas. The undated incident summary documented the resident was assessed and witness statements were obtained. Upon investigation, the resident was served lunch on 6/8/22 and was sitting up in bed to feed themself. The next time staff checked on the resident; the resident had coffee stains on their clothes. There were also skin tears on their left waist and center abdomen. The resident was immediately assessed by a RN and a treatment was initiated. The resident was reassessed by the Director of Nursing (DON) in the morning on 6/9/22 and it was decided the skin tears were opened burn blisters with minimal redness. The DON immediately notified medical for same day assessment. Coffee was poured in the kitchen and delivered to the unit for meals. Coffee temperatures were taken in the kitchen before meals. When first assessed by staff, it was thought the possible blister area was initially thought to be caused by an incontinence brief as it was in the same area as the brief waistline contact area. Upon further assessment by the DON, it was determined to be a blister from the resident has not reported any pain and no change in [their] routine [they] were at their baseline. The incident was reported to NYSDOH on 6/10/22 at 8:37 PM approximately 54 hours after the discovery of the skin impairment. When interviewed on 1/18/23 at 11:00 AM, CNA #37 stated they had seen the resident's abdominal area was red and blistered the morning of 6/9/22 while providing care. When the CNA asked the resident what happened, the resident told the CNA they spilled coffee on themselves. The resident had hand tremors and did not have lids on her cups. When interviewed on 1/19/23 at 11:48 AM, CNA #33 stated they first saw the burn when washing the resident up before dinner on 6/9/22. There were bubbles on their abdomen and chest. The CNA immediately informed the nurse. The resident's gown and linen did not have any coffee stains. When interviewed on 1/19/23 at 1:29 PM, the DON stated reportability determination was done using the NYSDOH reporting guidelines. Guidance was then requested from corporate if needed. The DON was unsure of specific reporting timelines. The DON stated using the guidelines, the Administrator and the DON made the determination if an incident needed to be reported to NYSDOH. The DON did not remember how the facility concluded the burn was caused by coffee spillage but thought a staff member reported seeing a coffee stain on the resident's linen or clothes. The DON stated the facility usually dated the investigation summary and did not know why this one was undated. For every incident, witness statements were obtained from all unit on-duty staff during a 24 hour look back period. Incident reports were initiated by the RN Manager, RN Supervisor, or unit LPN. All assessments were done by a RN. The Administrator and DON were responsible to ensure each incident report was thorough and complete. The Administrator was responsible for NYSDOH reporting. The DON stated they looked at the area after staff reported it to them and the area looked like it was a burn. When interviewed on 1/19/23 at 2:19 PM, the Administrator stated incident reports were reported based on the Nursing Home Incident Reporting Manual. They or the DON would report incidents after review of the incident report. Any incident with serious bodily injury was to be reported within 2 hours after suspicion and all other incidents of resident harm must be reported within 24 hours. The Administrator stated the incident report and checklist were reviewed over 5 days post incident to ensure thoroughness and completion. The Administrator stated the resident's burn was first noticed on 6/8/22 and looked like a skin tear when assessed. The blisters were noted on 6/9/22 at 5:45 PM, and the incident was reported on 6/10/22 at 8:37 PM. It was reported later than 24 hours whether the burn area occurred on 6/8/22 or 6/9/22. The Administrator stated they submitted the report to NYSDOH. The Administrator stated the facility determined the resident had some coffee colored stains on their sheets and that was how the facility determined what caused the burns. They could not recall who said they saw the coffee stains. The Administrator did not know why the investigative summary was not dated and timed, and therefore did not know when the summary was written. 10NYCRR 415.4 (b)(2)(3) 40803

Based on observation, interview and record review during the recertification survey conducted 1/11/23 - 1/19/23, the facility failed to ensure the resident environment remained free of accident hazards as is possible for 2 of 5 point of use water dispensers (Unit 1 resident lounge and Unit 3 South nursing station water dispensers) reviewed. Specifically, the point of use water dispensers in the Unit 1 resident lounge and at the Unit 3 South nursing station had hot water spigots accessible to residents that dispensed hot water measuring 161-166 degrees Fahrenheit (F). Findings include: There was no facility policy on point of use water dispensers. During an observation on 1/13/23 at 2:10 PM, the water dispenser at the Unit 3 South nursing station had a functional hot water spigot accessible to residents. The dispensed hot water was measured at 166 F. During an observation on 1/13/23 at 2:30 PM, the water dispenser in the Unit 1 resident lounge had a functional hot water spigot. The dispenser was accessible to residents in the open common area resident lounge. The dispensed hot water was measured at 163 F. During an interview on 1/13/23 at 2:30 PM, certified nursing assistant (CNA) #22 stated they had used the 1st floor resident lounge water dispenser to get hot water for residents. They had never seen staff from other units come down and use the hot water from the dispenser in the 1st floor lounge. They had never seen a resident use the water dispensers, but residents did have access to them. The CNA stated they added ice to a beverage if they thought it was too hot and according to how hot the cup felt. They had made hot cocoa for residents in the past using the hot water from the water dispenser. The CNA stated there was a thermometer next to the microwave that could be used to take food and water temperatures if needed. They stated they were not trained on how to use the thermometer for hot water from the water dispenser. They had not used the thermometer to test water temperatures in the past. During an interview on 1/13/23 at 3:14 PM, certified nurse aide (CNA) #8 stated residents did not use the water dispensers much on 3 South, but they did have access to the water dispensers on the unit. The hot water did not function on the water dispenser in the dining room, however the one at the nursing station on 3 South did function for hot water. They stated they had used the hot water from the 3 South water dispenser to make hot chocolate for a resident and it was really hot. They had to add cold water to it to cool it down before giving it to the resident. During an interview on 1/13/23 at 3:14 PM licensed practical nurse (LPN) #5 stated they used the hot water from the 3 South water dispenser to make tea for residents. The temperature was usually 165 F from the dispenser, and they let it cool to about 145 F before serving the residents and checked it with a probe thermometer. The water dispenser was accessible to the residents and there was the possibility for residents to be burned from the hot water if it was too hot. Staff were trained to reheat food and the food reheating policy and thermometer were available on all microwaves in the nursing office. During an interview on 1/13/23 at 3:18 PM, Resident #36 stated they had gone behind the nursing station on 3 South in the past to use the water dispenser for hot water. During an interview on 1/13/23 at 3:23 PM, CNA #24 stated they had used the hot water from the dispensers on 1 South and 3 South. They had made hot chocolate, tea, and coffee for residents using the hot water from the dispensers. They had not been trained on how to use the water dispensers or what temperature the water should be. They did not think thermometers were available. They stated they would test the water temperature prior to serving beverages to residents by feeling the cups and by looking for the steam coming from the cup. They would tell the residents to wait a while before drinking the beverage. They had seen residents use the hot water spigots on all the units. The residents were not supposed to use the water dispensers, but they did. During a collaborative interview on 1/13/23 at 4:01 PM with the Administrator, Regional Administrator and Consulting Corporate Regional registered dietitian (RD), the Regional Administrator and Administrator stated they were not aware any of the water dispensers on the units that had functional hot water. The Consulting Corporate RD stated the dispensers were usually never set up to produce hot water. Hot water should be 90 F to 120 F. During an interview on 1/18/23 at 12:15 PM, the Maintenance Director stated they were aware that the water dispensers had a hot water option. They thought the hot water switch had been disconnected from the water coolers when the new water dispensers were installed in the facility. There was no maintenance for the water coolers besides daily external cleanings, and there had never been any temperature checks done for the hot water coming from the dispensers. The 5 water dispensers were installed at the facility in April 2022. 10 NYCRR 415.12(h)(1)

Based on observation, interview, and record review during the recertification survey conducted 1/11/23-1/19/23, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 3 of 5 medication carts (Units 1 South, 2 South, and 3 South) and 3 of 3 medication storage rooms (Units 1 South, 2 South, and 3 South) observed. Specifically, Unit 2 South had expired stock medications in the medication cart and expired biologicals in the medication room; Unit 1 had an expired stock medication in the medication cart and medication room, and the medication refrigerator contained an expired biological; and Unit 3 had expired biologicals and insulin pens in the medication cart and an expired biological in the medication room. The facility policy Insulin Administration last reviewed 2/2022, documented all insulin was to be dated when opened and was good for 28 days. The undated facility policy Storage of Medications documented: - Any opened vials would contain an opened date. The nurse was to check the expiration date of each medication prior to administration. No expired medications would be administered to a resident. - The facility should not use discontinued, outdated, or deteriorated drugs or biologicals and such drugs should be destroyed. Each residents' medications would be assigned to an individual holding area to prevent the possibility of mixing medications of residents. During an observation on 1/12/23 at 10:21 AM with licensed practical nurse (LPN) #19, the following were observed in the 2 South medication cart: - an opened bottle of famotidine (Pepcid, reduces stomach acid) 10 milligrams (mg) with a manufacturer's expiration date of 10/21. The bottle had a handwritten opened date of 8/16/22 written on the bottle and there were 3 pills left inside the bottle. - an opened bottle of Vitamin C 500 mg with a manufacturer's expiration date of 4/21. The bottle had a handwritten opened date of 1/6/23. - an unopened bottle of simethicone (anti-gas) 80 mg with a manufacturer's expiration date of 12/22. During an observation on 1/12/23 at 10:30 AM with LPN #19, the following were observed in the 2 South medication room refrigerator: - Afluria (influenza vaccine) vial with an opened date of 11/9/22 handwritten on the box. - Tubersol (Tuberculin test) vial with no open date on the box or vial. When interviewed on 1/12/23 at 10:41 AM, LPN #19 stated that the famotidine, Vitamin C, simethicone, Afluria and Tubersol in the unit 2 South medication room and medication refrigerator were expired. Some were opened after the expiration date per the handwritten opened date on them and should not have been. LPN #19 did not know who opened them or if they were given to residents. The opened vials of Afluria vaccine and Tubersol test solution were considered expired 30 days after the open date. If there was no opened date written on the meds, they could not determine when they were opened and when they expired. LPN #19 stated they had not given any opened vial medications to residents and both vials were considered expired. During a 1 South B side cart medication storage observation on 1/12/23 at 10:55 AM with LPN #20, there was an opened bottle of Geri Mox (liquid antacid) with a manufacturer's expiration date of 11/22. During a 1 South medication room observation on 1/12/23 at 11:00 AM with LPN #20, there was an opened vial of Aplisol (Tuberculin test) in the medication refrigerator with no opened date. During a 3 South medication room observation on 1/12/23 at 11:00 AM with LPN #5, the medication refrigerator contained an open vial of Aplisol (Tuberculin test) with no opened date on the box or vial. The LPN stated they were unaware of when it was opened, and it expired after 30 days of opening. When interviewed on 1/12/23 at 11:05 AM, LPN #20 stated the open vial of Aplisol was good for 30 days once opened, there was no opened date on the vial, and was considered expired as they could not determine how long it had been opened. LPN #20 stated the Nurse Manager checked for expired medications on the unit routinely and each nurse was to check each medication's expiration date prior to administration. Medications should be discarded at the end of the month prior to the monthly expiration date and the day before if there was a more specific date listed. During a 3 South B side cart medication storage observation 1/12/23 at 4:26 PM with registered nurse (RN) #21, the following were observed: - bacteriostatic water, 2 multi-dose vials in a plastic bag. Both were opened and less than half full. They were labeled for Resident #10 and were not dated when opened. - Lispro (insulin) vial, opened with no date and labeled with the name of a resident no longer in the facility, - Lidocaine 1% (numbing agent) multi-dose vial was opened and was not labeled with an opened date. - 2 Glargine (insulin) pens, opened, labeled for Residents #56 and #89 and did not include an opened date. When interviewed on 1/12/23 at 4:28 PM RN #21 stated the Lidocaine 1% was used that morning to administer an antibiotic to a resident. RN #21 stated both the bacteriostatic water and Lidocaine 1% should have included the opened date. The insulin pens should have an opened date on them. RN #21 stated they were unsure how long the opened vials or insulin pens were good for once opened. They stated using expired insulin could be harmful to a resident. When interviewed on 1/19/23 at 11:20 AM, RN Unit Manager #11 stated medications should be checked at least weekly by unit nurses for expiration dates. Each nurse should check the expiration dates prior to administration. The medication should be discarded at the beginning of the expiration month or the end of the day prior to the expiration date. The RN Manager stated staff should not administer an expired medication to a resident. Opened vials were good for 30 days and should be dated with the opened date by the nurse opening the vial. If there was no opened date the vial should be discarded. 10 NYCRR 415.18 (d)

Based on observation, interview and record review during the recertification survey conducted 1/11/23-1/19/23, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 3 residential units (Unit 2) reviewed. Specifically, there were dead mice and mouse droppings found in multiple resident rooms. Findings include: The facility policy Pest Control revised 2/2022, documented staff would report pest sightings to the Maintenance Director via work order or email. If a pest situation was reported, maintenance may treat the area and would request the contractor come in as soon as possible to treat the area identified. The monthly facility pest control vendor reports dated 7/2022 to 10/2022 did not document the presence of mice. The General Comments section from the 11/1/22 monthly facility pest control vendor report documented customer also states mice activity is pretty heavy on the inside of the building. The 12/9/22 monthly facility pest control vendor report did not document the presence of mice. The facility Mouse Logs completed from 11/2022 to 1/2023 documented that mice were present and captured on the second floor unit. There was a mouse identified and captured in a trap within resident room [ROOM NUMBER], and multiple other rooms on the Mouse Log, which was indicated by a 1 on the spreadsheet. Pest control related work orders dated 10/20/22 to 1/10/23, documented on 12/8/22 work orders for mice were created for resident rooms [ROOM NUMBERS]. The following observations were made: - on 1/11/23 at 2:30 PM, in room [ROOM NUMBER] there were mouse droppings and a trap with a dead mouse on the floor near the head of the resident bed. - on 1/11/23 at 2:37 PM, resident room [ROOM NUMBER] had mouse droppings on the floor along the edge of the wall. During an interview on 1/13/23 at 12:43 PM, certified nursing assistant (CNA) #53 stated that two to three weeks ago there were three mice in resident room [ROOM NUMBER], and they scurried when the light was turned on. They stated that there had been mice in resident room [ROOM NUMBER], and they had seen mice in resident room [ROOM NUMBER] climbing up the TV cord. They stated that they had told the nurse but was not sure which one. During an interview on 1/13/23 at 12:54 PM, licensed practical nurse (LPN) #51 stated they had seen a mouse in a trap last night. They stated that the mice had been in the facility since it started getting cold about 3 months ago. They stated they had seen mice in resident rooms 272, 250, 259 and 260 and it was not acceptable for mice to be in resident areas. During an observation on 1/13/23 at 12:58 PM, there was a dead mouse in a trap on the floor under the wall heater in resident room [ROOM NUMBER]. During an interview on 1/12/23 at 4:27 PM, the Maintenance Director stated that the exterminator vendor was onsite on 1/11/23 for an emergency service, and that this had been scheduled prior to the start of the federal survey. They stated they were aware mice were caught in resident room [ROOM NUMBER]. On 1/13/23, between 2:28 PM and 3:22 PM, the following was observed: - resident room [ROOM NUMBER] had 2 mouse traps on the floor with dead mice, one near the head of the resident bed and one under the heater. - resident room [ROOM NUMBER] had mouse droppings under the heater. - resident room [ROOM NUMBER] had mouse droppings in three drawers of the nightstand. - resident room [ROOM NUMBER] had mouse droppings under the heater. - resident room [ROOM NUMBER] had mouse droppings on the floor near the window side resident bed. There was a hole in a wall near the droppings. During an interview on 1/13/23 at 3:26 PM, the Social Work Director stated that they had been made aware of mice on the second floor about a month ago by the residents on the floor and it was not acceptable for mice to be found in resident areas. They stated that a work order had been created each time they were told about the mice in resident rooms. During an interview on 1/17/23 at 10:45 AM, the DON stated if nursing staff had seen any mouse droppings inside nightstands/dressers, on floors, surfaces etc., they should notify maintenance to verify the observation, then the housekeeping department should clean the areas. They stated that resident rooms [ROOM NUMBERS] had mouse sightings, and they could not recall if the mouse sightings had been brought up during the last two monthly quality assurance meetings. During an interview on 1/17/23 at 11:03 AM, the Administrator stated they were notified of the mice on the second floor in November 2022 and maintenance created a mouse log in November. They stated the pest issue was mentioned during the last monthly quality assurance meeting. The Administrator stated they had requested staff to start looking at resident rooms more frequently. They stated in January 2023 the facility had a contract with a new pest control vendor, and that the pest sightings had decreased since the new vendor had started treating the facility. During an interview on 1/17/23 at 12:19 PM, the Maintenance Director stated they had been told about mouse sightings in room [ROOM NUMBER], and that the resident in the room was feeding them. They stated that they had received work orders from the 2nd floor nursing staff regarding mouse sightings, had created a monthly mouse sighting log, and that pest sightings had been brought to the attention of quality assurance meetings for the last two months. The Maintenance Director stated that once this mouse issue was brought to the attention of the third party pest control vendor, the vendor came onsite and placed glue boards in specific resident rooms where mice had been seen. They stated that the pest control vendor had recommended that the facility put door sweeps on outside doors and was provided with a stack of spare glue boards to place as needed. The Maintenance Director stated that in January 2023 the facility contacted another third party vendor, they came that same month for an initial assessment of the pest issue, and a contract was made on 1/6/2023 with the new vendor. They stated that the facility had been proactive in removing the mice, had taken immediate steps that included creating an internal facility monthly mouse log, and that the mice sightings had decreased since the new vendor had been at the facility. The Maintenance Director stated that a 1 on the mouse log indicated when a mouse had been captured in a resident room, and that the log was stopped when the new pest control vendor had taken over. During an interview on 1/18/23 at 9:29 AM, Resident #63 stated they had seen mice in room [ROOM NUMBER] and they had never fed any of them. 10NYCRR 415.29(j)(5)

Based on interview and record review during the abbreviated survey (NY 704), the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed (Resident #8). Specifically, - Resident #8 had multiple falls and thorough investigations were not completed to determine if the comprehensive care plan (CCP) was followed. - The resident was lowered to the floor by staff and there was no documented evidence the resident was assessed or that the incident was investigated. - Therapy recommendations for fall prevention (high back, reclining wheelchair) were not added to the resident's CCP. Findings include: The ,d+[DATE] revised Accident/Incident Reporting Policy documented: - all accidents or incidents must be investigated and reported to the Administrator and an accident/incident report must be completed for all accidents or incidents. - The Nurse Supervisor/Charge Nurse must be immediately informed of accidents or incidents so that medical attention can be provided. - The Nurse Supervisor and/or Charge Nurse should examine all accident/incident victims and inform the physician of the accident or incident and the designated representative. - The Nurse Supervisor/Charge Nurse and /or the department director or Supervisor must conduct an immediate investigation of the accident or incident which must be submitted to the Director of Nursing (DON) and reviewed by the Interdisciplinary Team at the next Risk Management Committee with additional revisions to the plan of care being implemented as indicated. - The original copy must be submitted to the Administrator after the occurrence of the accident/incident. The ,d+[DATE] revised Fall Prevention Program policy documented when a resident fell , was lowered to the floor, or found on the floor, they were to be assessed by the registered nurse (RN), the physician was to be called, orders documented, and the family or responsible party notified promptly of any fall incident regardless of whether there was obvious injury or not. Any resident who fell would have their care plan reviewed/updated by the charge nurse, nurse manager/supervisor. Resident #8 was admitted to the facility with diagnoses including dementia, repeated falls, and chronic pain. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, was independent with bed mobility, transfers, and ambulation, required supervision and set up for toileting, was always continent of bowel and bladder, and had no recent falls. The [DATE] comprehensive care plan (CCP) documented the resident was at risk for falls. Interventions included ensure proper lighting, eyeglasses, proper footwear/non-skid socks, clear pathways, physical therapy (PT) and/or occupational therapy (OT) screens as indicated, and toileting every 2 hours to assist with preventing episodes of incontinence. The resident was continent of bowel and bladder. The [DATE] at 7:30 AM, Incident Report, completed by registered nurse (RN) #8, documented the resident had an unobserved fall that was discovered by the licensed practical nurse (LPN). The resident was found sitting on the floor near the end of their bed and the floor around them was wet with possible urine. The resident had a hematoma (blood filled swelling) above the right eye and three skin tears. RN #8 documented the cause of the fall was the resident slipped on the wet floor and preventing a wet floor would keep the resident from slipping again. There was no documentation whether the resident's CCP was followed for 2-hour toileting. The CCP was updated and documented on [DATE], documented to ensure the floor was dry to prevent slipping. The [DATE] PT note documented the resident was seen related to a fall where the resident hit their head and presented with bruising that covered their face and neck. Nursing and CNAs reported resident had decreased independence with activities of daily living (ADL) and the resident hardly left the bed since the fall on [DATE]. Upon evaluation, the resident was severely confused and needed maximum encouragement to participate. They currently needed minimum assistance with bed mobility and transfers due to confusion and standby assist for ambulation. The [DATE] discharge PT note documented the resident was treated in therapy for recent falls. They met all goals and was independent with bed mobility and transfers, and distant supervision in hallway with ambulation There was no documentation the CCP for falls was updated between ,d+[DATE] and ,d+[DATE]. The [DATE] at 12:45 AM Incident Report by RN #7 documented after doing morning rounds, they heard a noise, found the resident on the floor and the resident had a skin tear on left hand. The resident had a second fall (did not document the time or circumstances surrounding the fall) and lacerated the left lateral eye. RN #7 documented they thought the resident stumbled on the bedside table as they were found next to it. CNA #46's statement, attached to the report, documented the resident was found on the floor at 12:45 AM and they seemed more confused then normal. CNA #46 entered the room with RN #7 who assessed and assisted the resident off the floor. RN #8 was also present and evaluated the resident. There was no documentation the facility determined whether the CCP was followed. The [DATE] RN#7's progress notes documented: - at 1:40 AM, a noise was heard and the resident was found on the floor between the bed and the bedside table. A skin tear was observed on the left hand. The Supervisor was notified and assessed the resident. - At 3:02 AM, the resident had a fall in the hallway and sustained a laceration of the left eye. The Supervisor assessed the resident. The resident was removed from the dementia unit, placed at the nursing station, and provided 1:1 supervision. The resident was restless, confused, and was to be monitored. The [DATE] at 1:46 PM, nurse practitioner (NP) #47 documented the resident was being seen for recurrent falls. Last evening, the resident had 2 falls and had joint pain in the left wrist, bruising to left elbow and hand, and bruising to the left temple. The [DATE] physician's orders documented [MEDICATION(S)] (pain reliever) 50 milligrams (mg) as needed for left rib pain every 8 hours and [MEDICATION(S)] (anti-anxiety) 1 mg as needed anxiety/agitation. The undated and unsigned Investigative Summary documented: - the resident was found in their room on [DATE] at 1:40 AM between their bed and bedside table. The RN assessed the resident and found a skin tear to their top left hand. - The resident had a second fall in the hallway on [DATE] at 3:02 AM. The RN assessed and found a laceration to the left eye. - Throughout the shift, the resident was restless, agitated and unsteady on their feet. - The provider was notified, Trazadone ordered, the resident brought to the nursing station for observation, and pain was monitored. - The resident was noted to be holding their rib cage and moaning and a new order was obtained for [MEDICATION(S)]. - On [DATE], the resident triggered for low meal intakes and weepiness. They received [MEDICATION(S)] as ordered. The resident was awake for portions of the overnight and wandered and was weeping. The RN attempted [MEDICATION(S)] but the resident refused. - On [DATE], the resident accepted pain medication but showed signs of pain. An x-ray was ordered with findings of healing fractures of 5th and 6th left ribs. There was no documentation whether a determination was made that the resident's CCP was followed at the time of both falls. The [DATE] (untimed) LPN #43's progress note documented the resident's family was concerned about the resident's pain. The resident was grimacing, holding their arm, and not stable on their feet. The CNAs lowered the resident to the floor when they were unstable when trying to walk. The Supervisor was made aware and staff were to monitor for unsteady gait and pain. There was no documentation the resident was assessed by the RN after being lowered to the floor and no documentation an Incident Report or investigation was completed when the resident was lowered to the floor by the CNAs. The [DATE] x-ray report documented the resident had healing fractures of left 6th and 7th ribs. There was no documentation the family was notified of the x-ray results. The [DATE] OT plan of care documented the resident was seen for significant decline in self-care and frequent falls. The resident was previously independent for transfers and supervision for further distance, and now required extensive assistance with ADLs. They were provided with a high-back reclining chair with bilateral poseys on arm rests (padding to arm rests to aide in positioning and fall prevention). There was no documented evidence the resident's CCP or the Kardex (care instructions) were updated with the use of the high back recliner with poseys. The [DATE] (untimed) RN #26's progress note documented they were called to the unit around 7:20 PM and the resident was observed on the floor, lying on their right side. The resident had skin tears on the left outer eyelid, left elbow, and left middle and right fingers. The [DATE] at 7:25 PM, Incident Report completed by LPN #44 documented the CNA heard a noise and found the resident lying on the floor next to the bed. A staff statement, attached to the report, documented they were in another resident's room doing care when they heard a loud bang and found resident on the floor on stomach with bleeding above eye. Nurse and Supervisor aware. The Incident Report did not document if care planned interventions were followed. The [DATE] (untimed) RN #4's progress note documented the resident's x-ray report revealed healing fractures to the left rib cage, NP #47 was notified, and no new orders were obtained. The [DATE] (untimed) LPN #45's progress note documented the resident was restless at 3:30 AM and given [MEDICATION(S)] (anti-anxiety medication). Staff called the nurse at 6 AM for a fall. The resident walked from their room to the dining room and was sitting on their bottom with back against wall. The resident was assessed by the Supervisor and placed in a wheelchair. The resident continued trying to stand and walk even after being placed in wheelchair. The was no documentation of the RN's assessment and no Incident Report or investigation. There was no documentation the use of [MEDICATION(S)] prior to the fall was reviewed. The [DATE] (untimed) nursing progress note documented the resident expired. On [DATE] at 2 PM, RN #8 stated in a telephone interview, when a resident fell , they were responsible to assess the resident, check vital signs, and complete an incident report. They reviewed the CCP and were required to document new interventions. They gathered statements from staff but did not ask staff whether interventions on the CCP were implemented and did not determine if the CCP was followed. When a resident was lowered to the floor, it was a change in plane, and they expected an incident report to be completed. They recalled the resident and did not recall the fall interventions in place for them. For the [DATE], and [DATE] falls, they did not determine if the CCP was followed. On [DATE] at 12:49 PM, in an interview with RN #26 they stated following falls, they were required to check vital signs, complete neurological checks, complete a full body assessment for injury, and start the incident report. They also were responsible for checking the CCP to be sure it was followed and spoke to staff to be sure the resident was toileted timely, and that staff were providing oversight. On the evening of [DATE], they were called to the unit to assess the resident. The resident was restless and agitated that night and rolled off the left side of the bed. They spoke with staff and got statements. They determined the CCP was followed, and they did not recall what interventions they put in place. They did not recall if the resident had a high back recliner with poseys in their room at that time. The [DATE] at 9 AM email from the Administrator documented there was no Incident Report for the resident's [DATE] fall on the night shift. For the [DATE] and [DATE] (day shift) falls, there were no investigative summaries completed because there were no CCP violations. On [DATE] at 11:42 AM, CNA #46 was called for an interview and a return call was not received. On [DATE] at 1:32 PM, RN #7 stated in a telephone interview, they worked the night shift. When a resident fell , the Supervisor was notified, an RN assessment was needed, an incident report was completed, and staff statements were obtained. They looked at the CCP to be sure it was followed and to determine if new interventions needed to be added. They recalled the resident and the fall on [DATE]. The resident had two falls that night that were very close together so they completed one incident report but wrote notes about both falls. The resident was on the locked dementia unit with limited staff present that night. After the falls, they removed the resident from the locked unit and brought them to the nursing station on the other unit because the resident was still attempting to walk, and they wanted to keep an eye on them. On [DATE] at 3:20 PM, the Director of Rehabilitation stated in a telephone interview, on [DATE], a high back reclining wheelchair with poseys was recommended for the resident to prevent falling and they expected staff to utilize the wheelchair/poseys when the resident was out of bed. Staff would know the wheelchair with poseys were to be used by looking under recommendations in the electronic medical record and the wheelchair/poseys would show up on the Kardex. They stated they did not see the wheelchair and poseys entered by the therapist on [DATE] and expected the therapist to have added the recommendation. On [DATE] at 3:41 PM, LPN #43 stated in a telephone interview, the RN needed to assess a resident before they could move a resident after a fall and if a resident needed to be lowered to the floor by staff, that was considered a fall. The resident was independent with ambulation and used to be able to speak with staff at one time. Towards the end though they became increasingly unsteady on their feet, became defensive when staff tried to assist them with ambulation and their cognition severely declined. They recalled the evening the resident was lowered to the floor on [DATE], did not recall if an incident report was started and they notified the Supervisor though did not recall who the Supervisor was. On [DATE] at 10:41 AM, RN #4 was called for an interview and a return call was not received. On [DATE] at 9 AM, LPN #45 stated in a telephone interview, the resident was confused, did not walk well, and used a wheelchair. On [DATE], the resident walked to the dining room on their own and was found by the CNA on the floor. They recalled the Supervisor assessing the resident that morning and did not recall if the Supervisor started an incident report. They did not recall the resident ever having a high back wheelchair with poseys. On [DATE] at 9:15 AM, RN #22 was contacted for an interview and no return call was not received. On [DATE] at 9:48 AM, RN #49 stated in a telephone interview, when a resident fell , an incident report was required. If a resident was lowered to the floor safely, they would not consider that a fall and would not do an incident report. They would have assessed the resident and written a note. On [DATE], they did not recall the incident of the resident being lowered to the floor, was not sure why they did not write a note, and did not complete an incident report. On [DATE] at 9:59 AM, NP #47 stated in a telephone interview, x-ray results typically were available within 4 to 8 hours, providers had access to reports through an electronic system, and the report was also faxed and/or results called to the facility. They stated when results were called to them 3 days after they were ordered, they were not sure why it took so long, and it was not done timely. On [DATE] at 11:12 AM, RN #4 Manager stated in a telephone interview, x-ray results were typically obtained within 24 hours. Nursing had the capability of looking up the report on the computer to get results and the provider and family would be notified immediately. The resident's x-ray was done on a Friday [DATE], they were off the weekend, and on Monday [DATE], they got the x-ray results when they came to work. Over the weekend, nursing should have obtained the results of the x-ray. NP #47 was responsible to notify the family. When a resident fell , they were assessed, an Incident Report was completed, and family and provider was notified. The CCP was to be reviewed and updated. The nurse completing the Incident Report along with the DON determined if the CCP was followed. On [DATE], they documented they reviewed and updated the CCP and that meant neglect was ruled out for the resident's fall. On [DATE] at 2:21 PM, the DON stated in a telephone interview, the facility could obtain x-ray results by either getting a phone call from the x-ray company or reviewing the report on the website. They expected medical and family to be notified immediately of x-ray results. On weekends, they expected the Supervisor to obtain results and nursing was trained in the process. They were not aware the resident's x-ray results were not reported to the NP for 3 days and that was not timely. When a resident fell , they expected an RN assessment, the CCP to be updated with new interventions, a note written, and an incident report completed. The Supervisor should obtain statements, talk with staff, and review CNA documentation to ensure the CCP was followed and it should be documented on the incident report that abuse and neglect were ruled out. When they reviewed the incident report, they were looking to be sure it was completed, and they also reviewed the incident at morning report. On [DATE], they expected the RN to ask the last time the resident was toileted. For [DATE], they did not recall completing the investigative summary. They expected 2 incident reports to be completed on [DATE] because there were 2 different incidents. When a resident was lowered to the floor, they expected the same procedure to be completed for falls. They were not aware on [DATE], the resident was lowered to the floor and an incident report should have been completed. They were not aware OT made recommendations for a high back wheelchair and they expected OT to have implemented the wheelchair and add it to the CCP. On [DATE], they were not aware an incident report was not completed when the resident fell in the dining room and there should have been one. 10NYCRR 415.12(h)(2)

Based on observation, record review, and interview conducted during the abbreviated survey (NY 514), the facility failed to ensure residents were free from abuse, neglect, misappropriation of property, and exploitation for 1 of 3 residents reviewed (Resident #1). Specifically, the facility did not ensure Resident #1 was free from abuse when the resident was held by their arms and ankles, yelled at by staff members, and was video recorded by staff while the event occurred. Findings include: The 3/10/16 facility Media policy documented employees were not to use social media sites while on work time. Staff were not to disclose any confidential information regarding patients using social media including video or photo sharing websites. Employees were strictly prohibited from using e-mail systems and internet access accounts or communicating, sharing or releasing any resident information, in any form, with any individual not authorized to have access to that information. The 6/21 facility Restraint Minimization Program policy documented restraints were not to be applied for discipline or staff convenience and were only to be used in circumstances in which the resident had medical symptoms which warranted such usage. Physical restraints were defined as any method which restricted movement including leg and arm restraints. The facility Abuse Prevention policy dated 12/20 and revised on 11/21, documented all residents would be free from abuse including verbal, mental, sexual, or physical abuse. No abuse or harm of any type would be tolerated, and the residents and staff would be monitored for protection. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 9/21/2021 comprehensive care plan (CCP) documented Resident #1 had behaviors including yelling, screaming, pounding on doors, disrobing, showing private area to others, physical aggression, and throwing furniture. Interventions included a colored stop sign to deter other residents from entering the room, offer the resident to sit with the Unit Manager, give a quiet place to read, and call the resident's child for assistance. The 11/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/12/21 registered nurse (RN) #6's progress note at 1:08 PM, documented Resident #1 had poor insight, minimal agitation, and irritable behaviors were noted. Hitting and repetitive movements were identified and the resident had a recent change in medication. Nursing interventions included redirection and encouraged to rest. The resident exited the room without clothing twice, squeezed staff's hand, and pushed staff away when staff attempted to redirect the resident to their room for clothing. The resident paced the unit for 15 minutes before agreeing to allow a shirt to be applied. The resident continued to walk the unit for another 30 minutes without pants then allowed staff to put pants on them. The resident was calm and walking the unit. The 11/22/21 RN #6's progress note documented at 12:23 PM, psychological services recommended to discontinue the morning dose of [MEDICATION(S)] 0.5 (mg). The family and medical provider were notified and agreeable. The 11/22/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The as needed [MEDICATION(S)] order continued. The 11/21 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/17/22 at 7:20 AM, a complaint was received at the New York State Department of Health (NYS DOH) that included video from a person alleging they received it from a staff member at the facility. The video included an unidentified resident in bed, and other individuals holding the resident's hands and ankles, and someone in the video yelling and using profanity. On 3/22/2022 at 10:54 AM, the complainant was interviewed via telephone and stated they received the video from an employee at the facility on 3/11/22 and was told the video was from 11/21. They would not state who sent them the video. On 3/24/22 at 8:34 AM, a surveyor entered the facility and at 9:30 AM and showed the video to the Administrator and Director of Nursing (DON). They identified the resident in the video as Resident #1 and the staff members in the video as a former employee, certified nurse aide (CNA) #2, and a current employee, CNA #1. There was one staff member in the video they were not able to identify and they identified the staff member recording the event as CNA #3. The video showed the following: - At 7 seconds, CNA #3 (recording the video) was running down the hallway recording their surroundings as an unidentified person was yelling. - At 8 seconds, CNA #3 (recording the video) entered Resident #1's room where CNA #2 was at the bottom end of the bed, holding onto Resident #1's ankles and one unidentified staff member was standing on the right side of the bed. Resident #1 was yelling. - At 10 seconds, an unidentified person laughed and stated, look at these (expletive). - At 11, seconds CNA #2 was holding onto Resident #1's ankles with both hands and CNA #1 was positioned at the head of the bed holding onto Resident #1's hands in their lap. The unidentified staff person remained standing on the right side of the bed and CNA #3 (recording the video) continued to record the event. - At 12 seconds, CNAs #1 and 2 looked at the camera and continued to hold the resident's hands and ankles. CNA #3 (recoding the video) scanned in closer showing CNAs #1 and #2 holding Resident #1's ankles and hands. - At 14 -21 seconds, CNA #1 told the resident to stop and continued to verbalize stop in succession louder each time. The resident yelled what in response. CNA #1's voice continued to rise while yelling stop and the resident began to yell stop. - At 21 seconds, CNA #1 began to laugh and looked at the camera while continuing to hold Resident #1's right and left hands and right thumb. - At 25 seconds, CNA #1 told the resident to chill, when the resident stated, it's you. CNA # 1 stated it's you in a loud tone. The resident stated, it is not. CNA #1 stated you tried biting me, enough. Then CNA #1 stated to Resident #1 lets act our age, you're a grown woman while throwing the residents hand' down towards their left side. The facility investigation summary documented: - on 3/24/2022, the NYS DOH informed the facility of an alleged case of abuse based on an anonymous video and the video prompted a facility investigation. - On 3/24/2022, the video was viewed and Resident #1 was identified as the resident in the video. - The video showed CNA #1 holding the resident's wrists and arms and CNA #2 holding the resident's ankles and feet. The CNA recording the event was identified as CNA #3 based on their voice. The fourth person was unable to be identified. - Resident #1 was admitted to the facility with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Behaviors included hitting, biting, slapping, kicking, punching with aggression towards other residents. - On 3/24/2022 when notified of the event, Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no changes in psychological or emotional status. - The facility conducted interviews with the identified staff from the video who were unaware of the video's existence. - CNA #1 identified themselves as holding the resident's arms and wrists and stated they thought holding the resident's hands was the best thing to do to prevent the resident from hitting them or going after other residents and staff. The verbal exchange of yelling at Resident #1 was documented as both the resident and CNA #1 were loud and there was no threatening, or derogatory language used. CNA #1 was remorseful and felt they did not handle the situation in the best way however they were trying to protect other staff and the resident. - CNA #2 left their employment with the facility in 12/21. They identified themselves as holding Resident #1's ankles. - The report documented on the day of the event, Resident #1 had an outburst and the staff were trying to protect themselves from getting hurt and were protecting other residents. - CNA #3 was interviewed and identified CNAs #1 and 2 as being in the video. CNA #3 did not recall the incident however did recognize their voice. When asked where they were during the video CNA #3 reported they did not recall, they had a bad memory and did not remember much. - Licensed practical nurse (LPN) #5 reported Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . At times, Resident #1's intramuscular medications were necessary to calm the resident. - CNAs #1, 2, and 3 acknowledged taking photos or videos of residents in any form was unacceptable and was a Health Insurance Portability and Accountability Act (HIPAA, a federal law requiring the protection of patient health information) violation. - The employees who had physical contact with Resident #1 did not have a grip that inflicted reddened or bruised wrists or ankles. Per the employees, they held the resident to prevent from being struck. - The facility concluded the employees were trying to protect themselves from being injured, the resident had no injuries or changes and there was no reasonable cause to conclude physical verbal or mental abuse occurred. The facility was not able to determine if the interaction rose to the level of abuse or was an inappropriate response to the interactions between staff and a resident with a history of aggressive behaviors. The conduct of all employees in the video was inconsistent with the facility work rules and standards of conduct and they had been terminated. On 3/30/2022 at 10:48/22, CNA #1 stated during an interview, they received training and education on abuse, neglect, and mistreatment while at the facility. Their understanding was defined as putting their hands on someone, verbally yelling at someone, and saying rude and disrespectful things. If they saw abuse occur, they would report it to the Supervisor or Director of Nursing (DON). They defined a restraint as holding someone down. Cell phone education and training was done in the facility and cell phones were not to be used while at work. No residents were to be discussed and pictures or video were not to be taken. Resident #1 could be aggressive at times, pulled hair, spit, bit and scratched. If the behaviors occurred, they would let the nurse know. They checked the resident's care plan daily as they worked everywhere in the facility. The video was viewed by this surveyor and CNA #1. After completion, CNA #1 stated oh that's so wrong. They stated they did not recall who took the video and stated there was verbal and physical abuse performed by them as they were holding down Resident #1's hands. They stated CNA #2 assisted them with Resident #1 and they did not report the event. They stated they were not aware of the video being recorded. They stated they did tell the nurse about the resident's behaviors and thought LPN #5 was on the unit at the time. On 3/30/2022 at 11:15 AM, CNA #2 stated during an interview, they received education and training on abuse, neglect and mistreatment while employed at the facility. CNA #2 defined physical abuse as restraining, hitting, or verbally calling the resident names. If they witnessed abuse, they would call the nurse or the DON and write a statement. Restraints were defined as holding someone down. The facility protocol was no cell phone use, pictures or videos were to be taken while working. Resident #1 had dementia, bad behaviors including pushing, biting, spiting, kicking, and scratching. The resident's care plan documented if the resident had behaviors, staff were to sit and talk calmly to the resident. If those interventions did not work, they were to notify the nurse. The video was reviewed with CNA #2 and they stated they were holding the residents feet so the resident did not kick anyone in the face. Resident #1 had behaviors most of the shift. They told the nurse and while waiting for the nurse, CNA #3 shot the video. CNA #1 walked with the resident to the room and the resident was calm at that time. They did not know what happened after that and they heard the resident yelling and returned to the room. They saw the resident kicking; CNA #1 was holding the resident's hands down and they grabbed Resident #1's feet. They stated the resident remained in that position for about four minutes. On 3/30/2022 at 11:40 AM CNA #3 stated during an interview, they received facility training on abuse, neglect, and mistreatment. Abuse was defined as physically hitting or holding someone against their will. Verbal abuse was defined as how you talk to someone or yelling at someone. If they witnessed abuse, they would report it to the head nurse or Supervisor. They were unable to define what a restraint meant. They stated they were aware of the cell phone policy and staff were not allowed to use their phones on the unit and were not allowed to take pictures or videos. Resident #1 had mood swings. The resident could be sweet and aggressive, and their moods were random and switched. The resident's CCP stated if the resident was combative to tell the nurse and walk away and reapproach. CNA #3 stated they recognized their voice on the video and felt abuse occurred in the video, they did not recall if they reported the event, did not recall when the event occurred, and did not recall making the video. On 3/31/2022 at 8:42 AM, LPN #5 stated during an interview, they worked as the Charge Nurse on the dementia unit (resident's unit) on the evening shift. Resident #1 had dementia and behaviors. The resident was combative and lashed out at staff. The resident was not easily redirected when combative and staff were to watch the resident, redirect if able, and report behaviors to the nurse. Non-pharmacological interventions included activities, offer foods and drinks, and walk with the resident. If the resident was yelling out, the staff were to redirect and offer non- pharmacological interventions. If Resident #1 had behaviors the staff were to leave and reapproach the resident. Resident #1 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #5 stated they would try all non-pharmacological interventions prior to administering as needed medication. And if they got to that point, the Supervisor would be notified and the event would be documented in the medical record. Resident #1 had several instances when their behaviors escalated, and the LPN had to ask staff to redirect Resident #1 to their room. They did not recall any specific event. They stated there may have been an event involving four staff members assisting with the residents behaviors however the staff were not to restrain the resident and they did not recall any event where staff restrained the resident. Staff were not allowed to use their phones while on the unit. After discussion of the video with the facility, they stated they identified the staff's behavior as inappropriate and would not condone the behavior. LPN #5 stated no staff reported the evening in the video to them. On 4/21/22 at 8:37 AM, RN #6 stated during a telephone interview, Resident #1 had dementia was able to answer yes and no questions and did not talk much. The resident spent a lot of the day walking up and down the hallways without purpose. At times, the resident disrobed and became agitated when redirected. Behaviors including hitting which occurred when staff intervened with the resident's line of walking. They had not seen aggressive behaviors from the resident in a couple of months. Staff were not to attempt to stop the resident from walking, just walk beside them. When agitation occurred, other residents were moved to safer areas until the resident calmed. If staff go about it the right way, agitation does not occur. Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When they reviewed the video, they identified the staff did not address the resident appropriately when yelling and restraining the resident. On 4/21/22 at 11:43 the Administrator stated during a telephone interview, the facility was a restraint free facility. Restraints were defined as holding someone down or preventing movement. Cell phones were not allowed to be used on the units and no videos or pictures were to be taken of residents unless consent was obtained. Abuse was not tolerated at the facility. If staff witnessed abuse of any kind, they were to stop the abuse and immediately report the incident. When notified of the video the facility investigated, obtained statements, and reviewed the video. The facility concluded the staff displayed inappropriate behaviors and they were terminated from employment. Review of the video showed the resident's feet and wrists being held, a cell phone being used, and video being taken of Resident #1. They did not recall foul language being used however did recall yelling by the resident and CNA #1. 10NYCRR 415.4(b)

Based on record review and interview during the abbreviated survey (NY 514), the facility did not ensure provision of services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 1 of 3 residents reviewed (Residents #1). Specifically, the facility did not ensure requested documentation and information was provided to the New York State Department of Health (NYS DOH) in a timely manner, resulting in a delay of the survey process in regard to an abuse allegation involving Resident #1. Findings include: On 3/23/22, an onsite abbreviated survey was conducted to investigate an abuse allegation made against staff members towards Resident #1. A formal written request for Resident #1's medical records was made with direction to send the information via Secure File Transfer in the Health Commerce System. On 3/29/2022 at 6:04 AM, an email was sent to the Administrator documenting the resident's medical records had not been received via SFT. On 3/30/22, an onsite visit was conducted and a request for Resident #1's medical records was again made as the resident's medical records had not been received. On 4/1/2022 at 5:30 AM, an email request was sent to the Administrator for Resident #1's medical records as the information was not received via SFT. On 4/4/2022 at 7:30 AM, an email request was sent to the Administrator documenting Resident #1's medical records and the facility investigation was not received via SFT. On 4/5/22 at 7:33 AM, an email request was sent for the resident's medical records as none had been received at that time via SFT. The email documented a request to send the resident's records via SFT and if that did not occur, the surveyor requested a printed version of the records to be available for pick up upon arrival to the facility at 10:00 AM. Upon arrival at 10:00 AM, the resident's printed records were obtained by the surveyor and the facility investigation into the abuse allegation was not part of those records. The Administrator stated at that time, the facility investigation was sent via SFT. At 12:07 PM on 4/5/21, only the summary of the investigation was received via SFT and the full investigation was not provided. On 4/6/2022 at 6:37 AM, an email was sent to the Administrator documenting the facility investigation summary was received and noting that the requested nursing notes from 10/15/2021 to 11/30/2021 had not been received. All nursing notes from 10/15/21 to 11/30/21 were not received prior to exit. On 4/18/22, staff phone numbers were requested from the Administrator. 4/19/22 at 7:19 AM, a request was made for the same staff phone numbers. On 4/21/2022, an email was received from the Administrator with the requested phone numbers. 10 NYCRR 483.70(i)

Based on interview and record review conducted during the COVID-19 Infection Control Focus Survey completed on 12/17/20, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to properly prevent and/or contain COVID-19, for 1 of 1 health care personnel (certified nursing assistant, CNA #5) who reported symptoms consistent with COVID-19. Specifically, CNA #5 reported feeling ill when screened at the beginning of her shift and was permitted to remain at the facility and provide care to residents after a negative [MEDICATION NAME] test (point of care, rapid test). Additionally, staff self-screening discrepancies for CNA #3 and transporter #13 were not clarified, and CNA #4 indicated no symptoms but was observed to be ill while working on the unit and was subsequently sent home. Finally, CNA #5 was floated between both COVID-negative and COVID-positive units. Findings include: The 3/11/2020 New York State Department of Health Dear Administrator Letter (DAL) #20-04, titled COVID-19 Guidance for Nursing Homes-revised, documented: If a staff person is found to be ill upon screening, the nursing home should send the person home and direct them to contact their primary care physician immediately. If the nursing home has reason to be concerned that the person may be infected with COVID-19, the nursing home must send the person home and contact the New York State Department of Health. The New York State Department of Health Health Advisory, COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/20, documents that when there are positive COVID-19 cases in a nursing home: Do not float staff between units. Cohort residents with COVID-19 with dedicated HCP and other direct care providers. Minimize the number of HCP and other direct care providers entering rooms. The 10/17/20 New York State Department of Health guidance, Interim Recommendations for Use of [DIAGNOSES REDACTED]-CoV-2 [MEDICATION NAME] Tests During COVID-19 Public Health Emergency, documented: If a symptomatic individual has a negative [MEDICATION NAME] test result, perform confirmatory laboratory-based RT-PCR (polymerase chain reaction) immediately and test for other respiratory pathogens. Quarantine until RT-PCR results are obtained and stay home from school or work. The Centers for Disease Control and Prevention (CDC) guidance, Preparing for COVID-19 in Nursing Homes, updated 11/20/20 documented: Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. The facility policy COVID-19 Action Plan revised 12/4/20 documents health checks for all HCP and other facility staff will be completed at the beginning of each shift. This includes all personnel entering the facility regardless of whether they are providing direct patient care. HCP and other facility staff with symptoms or with T (temperature) greater than or equal to 100.0 F will be sent home, and HCP and other facility staff who develop symptoms or fever while in the facility will immediately be sent home. During an interview with the Director or Nursing (DON) on 12/17/20 at 10:00 AM, she stated there were currently 69 residents in the facility positive for COVID-19. The residents resided on all of Unit 1, Unit 3S and 3D (separated by double doors). The DON stated there were currently 24 staff members out of work who were positive for COVID-19. The Staff Screening Log dated 12/17/20 documented CNA #3 did not answer the screening questions regarding any symptoms; CNA #4 did not report any symptoms on her screening; CNA #5 documented symptoms of a cough and sore throat; and transporter #13 replied both yes and no for the question lost sense of smell and/or taste. On 12/17/20 at 10:35 AM CNA #4 was heard vomiting in the restroom on Unit 3. When questioned, she stated she was feeling very ill. The surveyor directed her to see her supervisor immediately. On 12/17/20 at 10:50 AM, CNA #5 was interviewed and stated she felt ill and had symptoms including a sore throat, migraine headache, and vomiting. She told the IP/ADON (Infection Preventionist/Assistant Director of Nursing) she was symptomatic. She stated she had a rapid test in the facility and the results were negative. The CNA stated she was then told she must continue working. She was assigned to both the COVID-19 positive and negative residents on Unit 3. The 12/17/20 Daily Staffing (for 7AM-3PM shift) sheet documented: CNA #3 was scheduled on Unit 2N, CNAs # 4 and 5 were scheduled to work on Unit 3D. CNA #4 was noted as being late. CNA #5's timesheet dated 12/17/20 documented she clocked in at 7:18 AM and clocked out at 12:24 PM. On 12/17/20 at 12:15 PM the IP/ADON stated she was aware CNA #5 was not feeling well and was tested upon arrival in the morning. CNA #5's [MEDICATION NAME] test (rapid test) was negative and she asked CNA #5 to continue to work. She was overwhelmed with trying to find staff coverage due to the number of staff out with COVID-19 and there were many call outs due to weather conditions that morning. It was not ideal to have a sick employee working and they were trying to find someone to replace CNA #5. She stated in the past few days, CNA #5 and other staff had reported symptoms and she viewed some of it related to anxiety, as staff were tired and fearful due to the recent COVID-19 outbreak in the facility. She encouraged staff to keep working following a negative result from the rapid test because they could not find replacements for them. CNA #5 reported she had stopped vomiting prior to coming to work, and that was the reason she had CNA #5 continue to work. CNA #4 had an [MEDICATION NAME] test after she learned CNA #4 was ill and it was negative. CNA #4 was sent home immediately following her test because she was still experiencing nausea and vomiting. CNA #4 should have reported her symptoms immediately before going to the Unit to work or as soon as she felt ill. On 12/17/20 at 12:55 PM, registered nurse (RN) Unit Manager #1 stated if staff were ill or had symptoms, they received the [MEDICATION NAME] test and if it was negative, they were encouraged to stick it out. The receptionist or whoever is at the desk did the staff screening. If no one was there, staff were to self-screen and the supervisor was supposed to review the sheet. If it was an off-shift and someone had symptoms, all RNs knew how to Polymerase Chain Reaction (PCR) swab, but she was not certain about rapid tests. During an interview with the DON and IP/ADON on 12/17/20 at 3:45 PM, they stated if staff arrived early and no one was at the reception desk, they were to self-screen and record it on the screening log. The individual who arrives on duty to screen is responsible to review the self-screens and report any concerns or discrepancies to the DON or ADON. Staff were also expected to self-report to a supervisor if they were experiencing symptoms upon arrival or at any point during their shift. The 12/17/20 staff screening should have been clarified by the DON or IP/ADON regarding the incomplete and unclear responses for CNA #3 and transporter #13 to ensure they were non-symptomatic and cleared for work. The facility did not have a means to print the results of the rapid tests completed at the facility and stated CNAs #4 and 5 were negative when tested today. Transporter #13 reported to them he made an error and should have marked no as he was not experiencing any loss of taste or smell. The DON and IP/ADON were unaware there had to be a confirmatory PCR test following a negative [MEDICATION NAME] test for symptomatic employees. 10 NYCRR 415.19(a)(1),(b)(3); 400.2

Based on observations, record review and interviews conducted during the abbreviated survey (NY 101 and NY 638), for 10 of 11 sampled residents (Resident #1, 2, 4, 5, 6, 7, 8,9 10 and 11), the facility did not ensure each resident received adequate supervision to prevent abuse. Specifically, Resident #1, 2 and 5 were involved in physical altercations with Resident #3, Resident #4 was involved in altercations with Residents #5 and 8 and 10. Resident #5 had multiple altercations with Residents #6 and 4 and Resident #6 had altercations with Resident #3 and 11. The facility did not ensure the resident's safety was maintained resulting in continued multiple altercations. This resulted in actual harm that is not immediate jeopardy for Resident #2,5 and 6. Findings include: The Resident to Resident facility policy dated 11/26/2016 documented residents were to be free from abuse, neglect and exploitation. All incidents were investigated, and during the investigation the facility would take every precaution to protect residents from harm. The facility standard of practice protocol dated 1/27/2017 documented safety rounds and monitoring was a system of rounds on all shifts to ensure resident safety was maintained, nursing was responsible and the rounds were to be done every 2 hours. There was no documented evidence to support the residents had a program of hall monitoring. 1) Resident #3, Age 61, Date of Admission 10/12/2017, Significant [DIAGNOSES REDACTED]. The Minimal Data Set ((MDS) dated [DATE] documented the resident's cognition was severely impaired and he had physical behaviors towards others. The mental health consultation report dated 8/18/2017 prior to admission to the facility documented Resident #3 was admitted from home after increased agitation. He became violent, the police were called, he threw things, and was endangering his wife. Multiple medications were trialed with recommendations of decreasing the [MEDICAL CONDITION] medications exploring non-pharmalogical interventions to address his agitation and continue to pursue placement. The undated resident care guide (care instructions) documented the staff were to anticipate resident needs, supervise ambulation at a distance, when showing signs of aggression attempt to redirect with favorite foods and staff were not to show fear as it triggered the resident's behaviors. The resident was to be encouraged to be in high visibility, encouraged to be out of his room, observations when the resident was awake and in the hallway and when interacting with residents. The CCP dated 10/12/2017 - 12/2017 documented the resident had the potential to abuse others related to dementia and a violent past. The goal was to decrease resident to resident altercations. The specialized behavioral unit had a current census of 34 residents. Resident #3 was located in the middle room (219), Resident #1 was located in room [ROOM NUMBER] next to Resident #3's room with a shared bathroom, Resident #2 was located in room [ROOM NUMBER] next door to Resident #3 and Resident #5 was located across the hall and 2 doors down from Resident #3 at the time of the abbreviated survey. The Resident to Resident altercation were as follows: -On 10/12/2017- Resident #3 was resistive with care and became abusive towards staff during care. Interventions included approach in friendly manner, monitor and redirect as needed to avoid physical altercations. On 11/9/2017 the Nurse Practitioner (NP) completed a medication review, determined a gradual dose reduction (GDR) for Resident #5's [MEDICATION NAME] (antipsychotic) from 5 milligrams to 2mg had failed which caused an increase in his behaviors. His [MEDICATION NAME] (antidepressant) was also decreased at that time. The [MEDICATION NAME] was increased to 5 mg and he would be monitored closely. -On 11/29/2017 at 5:30PM an altercation between Residents #3 and 5. Resident #5 sustained a bruise to his right forearm measuring 2.5 centimeter (cm) x 1 cm. Resident #3 did not sustain injury and did not have any new interventions documented on his CP. Resident #5 had a stop sign placed at his door entrance. Nursing staff requested a new medication review be conducted and one was to occur on 12/1/2017. There was no documented evidence the resident was being monitored. The NP note dated 12/1/2017 documented the resident was seen for increased pain in his thigh related to an abscess. There was no documentation he had a medication review for his behaviors. There was no documented evidence of adequate supervision and psychological well being was maintained. -On 12/24/2017-altercation between Resident #3 and 1. Resident #3 demonstrated increased agitation and aggression prior to the incident and was ambulating down the hallway naked. He became combative, scratching, hitting, biting and grabbing at staff. Resident #3 was redirected back to his room and staff monitored him from the doorway, he entered the bathroom when Resident #1 was finishing and Resident #3 pushed Resident #1 and Resident #1 fell to the floor. No injuries were identified. There was no documented evidence of adequate supervision and psychological well being was maintained. No new interventions were initiated for Resident #3 on his plan of care. -On 12/26/2017 at 7:30 AM, an altercation between Resident # 3 and 5. Resident #3 entered Resident #5's room, it was unclear if the stop sign was in place prior to the incident. Resident #3 had previously demonstrated removing the stop signs from the doorways. While Resident #5 was attempting to get Resident #3 out of his room, Resident #3 pushed him to the floor. Resident #5 sustained an abrasion to his left temple. Resident #3 then showed aggression towards CNA #1 and she sustained scratches to her right upper arm. There was no documented evidence of adequate supervision and psychological well being was maintained. New interventions documented on the residents CP were to have a medication review. -On 12/26/201 at 7:50 PM, Resident #3 and 2 had an altercation. Resident #3 was ambulating in the hallway, approached Resident #2 and began to punch him in the face and knocked him to the floor. Resident #2 sustained a laceration to the left side of his mouth with visible blood, and was visibly upset. There was no identified trigger prior to the incident. Temporary (24 - 48 hours determined by the interdisciplinary team) 1:1 supervision was initiated until the interdisciplinary team was able to meet. The team met at 9:45 AM the following morning. Interventions were medical evaluation and medication review with a possibility of [MEDICATION NAME] (antianxiety medication). There was no documented evidence the staff provided 1:1 and no documented evidence preventative measures were initiated to ensure other residents remained safe. -On 1/5/2018 at 8:00 PM a CNA was sitting in the hallway monitoring Resident #3 ambulate in the hall. Resident #2 approached CNA and when Resident #3 passed them he turned around and approached them and pushed Resident #2 in the chair. No injuries resulted from the incident. The facility determined there was no malicious intent from Resident #3, he had poor safety awareness and did not have altercations involving pushing other residents. Intervention was the activity department was to schedule more afternoon activities. Resident #1 was observed on 1/2/2018 at 9:51 AM, on Unit 2 in room [ROOM NUMBER] sleeping on his bed. The bathroom was a shared bathroom between resident #1 and 3. Resident #2 was observed on 1/2/2018 at 9:47 AM, on Unit 2 in room [ROOM NUMBER] sleeping on his bed. His room was located next to room [ROOM NUMBER]. Resident #3 was observed on 1/2/2018 at 9:42 AM in his room. His roommate was wandering in and out of the room past Resident #3's bed. Resident # 5 was observed on 1/2/2018 at 9:39 AM in his room [ROOM NUMBER]. The room was located across the hall and 2 doors up from resident #3. A stop sign was across his door way. He was interviewable with some confusion and did not have any issues to report. Resident #3 was observed on 1/8/2018 at 7:55 AM, he was ambulating in the hallway with other residents. Resident #3 was assisted into the day room with another resident sitting across from each other. The staff remained in the hallway, not within view of the resident from 7:55 AM to 8:20 AM. At 8:20 AM a brief 15 second observation was done by CNA #1, who then returned to the hallway. When interviewed on 1/2/2018 at 11:50 AM CNA #1 stated Resident #3 was a very aggressive resident and at times required 3-4 staff to provide his care. Staff were to keep an eye on him as he wandered. No staff were assigned to provide one to one supervision, she felt this should be an intervention however the facility did not have that prevention in place. Resident #5 was easy going and he did wander. Both residents were assigned to the same hall on the locked unit 2. On 12/26/2017 the housekeeper yelled for help and found Resident # 3 standing over Resident #5 swinging at him in his room. The staff intervened and Resident #5 had a visible injury to the side of his head. When staff entered Resident #5's room he did not have the stop sign on his door per his plan of care. CNA #1 was unsure how the sign was removed. RN #4 was notified, Resident #3 was escorted to the dining room while staff continued with their assigned duties. After the incident occurred Resident #5's care plan was updated to ensure his stop sign was in place and a staff member was assigned to monitor the hallway. Monitoring the hallway by staff consisted of a staff member to be present in the hallway to ensure residents safety however that did not always occur due to limited staff and resident care. If staff were busy they were able to utilize the nurse however if she was passing medications from the other side of the door on the locked unit she was not able to see the residents. There were no specific assigned staff for the hall monitoring or documentation of who and when the monitoring occurred. Resident #3 had a prior room change as he had a verbal exchange and attempted to hit his previous roommate. When interviewed on 1/2/2017 at 2:04 PM CNA# 3 stated she provided care for Resident #3 and Resident #5 while on unit 2. Resident #3 required total assistance for care, he was very combative and abusive towards staff and residents. Interventions for some residents were stop signs that Resident #3 often removed and it did not stop him from entering resident's rooms Staff were to monitor the hallway and at times that was difficult to continually monitor the hallway as other resident's needed assistance. It was physically impossible to monitor Resident #3's every move. There was no specific staff assigned to the hall monitoring and the staff verbally communicated who would do it and when staff were busy they did the best they could. On 12/26/2017 while in the hallway, the medication nurse asked her where a resident was. She noticed Resident #3 was not in the hallway, went to locate him when she heard Resident #5 yell. She responded and saw Resident #3 push Resident #5 into the door frame, resulting in a bruise to the right arm. Resident #3 left, she went to obtain equipment to get vital signs on Resident #5 and was not sure who was monitoring the hall. Someone notified the supervisor, ice was applied to his arm and the nurse left. She did not know what new interventions were initiated at that time. Sometime later a stop sign was placed on Resident #5's door to deter the resident from going into the room. On 12/26/2017 she reported while she observed the hallway, another resident asked for assistance. Once she completed the task she observed Resident #3 push Resident #2 to the floor so hard he stepped out of his shoes. She intervened, separated the residents, notified the nurse and Resident #3 was placed on 1:1 supervision for a brief period of time. When she returned the following day the 1:1 had stopped. Resident #3 remained combative and at times when passing another resident in the hall. When re-interviewed on 1/8/2018 at 8:20 AM CNA #1 and CNA #9 stated they both had been attacked by Resident #3 causing scars and bruises that were visible on their body. They stated that day Resident #3 was to have his scheduled shower and due to his aggressiveness and unpredictability it usually required 4 staff members. When interviewed on 1/8/2017 at 2:01 PM, social worker #8 stated she was aware of the incident that occurred on 11/9 between Resident # 3 and 9. Resident #9 was moved to a private room located in the same hallway. The CP intervention for Resident #3 was to anticipate his needs, monitoring for resident safety, ensure stop signs were in place, monitoring the hall way and observe. No 1:1 was initiated. The CP was reviewed at that time, incidents on 11/29/2017 and 12/24/2017 did not document new interventions as the interventions in place were continued. On 12/26/2017 after the incident she did not want to meet with the resident as it may have caused increased behaviors. She met with the Unit Manager and stated she would like to discuss Resident #3's behaviors at the next gradual dose reduction (GDR) meeting. She reported she was not made aware of any incidents involving Resident #3 during the month of (MONTH) (YEAR) and she did not feel his being in a room with another resident was a concern. When interviewed on 1/8/2018 at 3:15 PM The Nurse Practitioner (NP) stated when a resident had behaviors and was unable to be redirected she was contacted. At times with limited staff availability it was difficult to keep an eye on the resident. Prior to admission Resident #3 had aggressive behaviors related to his dementia. On 10/12/2017 when admitted he became aggressive towards staff when care was provided. Attempts were made to, observe, monitor, redirect and review his medications with adjustments. The changes in those medications were not successful. She identified when he was in close contact with others he became violent and when staff monitored they did not consistently identify any triggers. She was unable to determine the psychological harm that may result for the continuous resident to resident altercations and stated Resident #3 had the potential to hurt other residents on the unit. When interviewed on 1/9/2018 at 7:45 AM The Director of Nursing (DON) stated the facility incident reports were completed on the unit and reviewed during the morning meeting with the disciplinary team. New interventions for residents were discussed and initiated after the meeting. When an incident of resident to resident altercation occurred she and the Administrator were notified at the time of the incident and immediate interventions were initiated. The CP was updated by her or the social worker and new interventions were added unless it was a medication review. When resident to resident occurred, the staff monitored from the doorway if a resident was in the room and they were to maintain a safe distance between residents. Hall monitoring consisted of staff, when available, to have eyes on the residents involved in the altercation however, that, did not always occur as staff needed to provide care needs for other residents. When Resident #5 became more mobile he became more combative with care. A male care giver was initiated to help, however, that was not always possible and did not always work. Intervention for safety for other residents was staff to monitor the hall. She had not observed any issues with the resident and his roommate. If Resident #3 was in the dayroom with another resident her expectation of staff was to monitor the residents in close proximity, staff would stand in the room for a period of time and then complete safety checks every 2 hours and attempt hourly checks. When interviewed on 1/9/2017 at 8:27 AM The Administrator stated she was made aware of all resident to resident altercations and was aware she had multiple resident to resident altercations incidents occur in the facility. The incidents that the facility felt were reportable to the New York State Department of Health (NYSDOH) were incidents that identified an intent to harm. Actions taken for protection of other residents after altercations were to review the incident/accident report with a multidisciplinary approach, review behavior notes and have social services and medical follow up with the resident. She monitored for potential abuse by providing training to the staff, increase activities, looking at the time of the incident, pay attention to supervision and use Unit Assistants to meet some resident needs. There was no documented evidence to support adequate supervision and psychological well being was maintained. 2) Resident #4, Age 62, Date of Admission 4/25/2016, Significant [DIAGNOSES REDACTED]. The Minimal Data Set ((MDS) dated [DATE] documented the resident's cognition was severely impaired and she did not have behaviors. The CCP and resident care guide (care instruction) dated 5/15/2017 documented the resident was to be encouraged to engage in activities. rest, frequent observations for safety, high visible areas, maintain a safe distance from other residents that pace the unit and redirect. Resident #4's CCP initiated 7/26/2017 and revised on 11/3/2017 documented Resident #4 was a recipient of altercations with other residents on the following dates: -7/27/2016,7/29/2016, 8/17/2016, 8/20/2016, 11/23/2016, 11/27/2016, 11/28/2016, 12/14/2016, 1/6/2017, 1/25/2017, 1/26/2017, 2/22/2017, 4/9/2017, 4/26/2017, 5/3/2017 and 10/15/2017. Resident #4 initiated altercations with other residents on the following dates: 9/18/2016, 10/12/2016, 3/20/2017, 4/26/2017- altercation with another resident. -On 9/28/2017 at 3:45 PM Resident #4 was observed grabbing Resident #10 around his face, squeezing and pulling him backwards. The RN Supervisor was notified and an assessment was completed at 5:40 PM and no injuries were identified. The investigation revealed the facts did not support the allegation of resident to resident altercation. Interventions were Resident #4 was to have frequent checks/observations for safety for the resident and all other residents and to direct Resident #4 away from others. Resident #10's interventions were to keep him in high visibility areas and he was not to be unattended while in his wheelchair. -On 10/16/2017 at 9:10 PM Resident #4 had a history of [REDACTED].#5's room and was found in the room mates bed. Resident #5 was upset. While being directed out of the room by staff Resident #5 pushed staff out of the way and grabbed Resident #4 and pushed her out the door into the medication cart. Resident #4 was care planned for the potential to be abused by others for wandering into other resident's rooms. Interventions in place were distraction, offer foods and fluids and ambulate with the resident as she allowed, attempt to maintain safe distance from other residents that pace the unit and encourage distance. No injuries resulted from the incident. -On 11/24/2017 at 2:50 PM, CNA #6 was asked to retrieve Resident #4 out of Resident #7's room. When she entered the room, she observed Resident #7 hugging Resident #4 in an attempt to remove her from the room. CNA #6 told Resident #7 to let go of the resident when Resident #4 pushed Resident #7 and she fell along with Resident #4. The facility determined there was no evidence of abuse, neglect or mistreatment. No injuries identified. -On 11/27/2017- Resident #4 was provided her lunch tray in the dining room. Resident #4 was to have finger foods for meals as she was unable to sit for any length of time. Resident #4 approached Resident #8, struck him in the face and attempted to take his food. Resident #4 was redirected. The resident had been demonstrating increased anxiety over the past few days including grabbing other resident's foods. Interventions were a medical review with an increase in pain medication and dietary evaluation. No injuries identified. The goal documented on the CP on 7/26/2017 documented the resident was to remain safe and without injury through the next review. No other goals were documented through 11/2017. There was no documented evidence of adequate supervision and psychological well being was maintained. The NP note dated 11/27/2017 documented she evaluated Resident #4 due to increased behaviors as she had two altercations with other residents where she pushed a resident and slapped a resident in the face within the past 3 days. No recent medication changes were made prior to the reported incidents. A [MEDICATION NAME] for pain was increased from 12 mcg (micrograms) to 25 mcg. Behavior was to be monitored and there was no documented behaviors identified. When observed on 1/2/2018 at 9:34 AM Resident #4 was in her room sleeping on her bed. She had a private room located on unit 3 designated as a secured dementia unit. When observed on 1/8/2018 at 9:45 AM Resident #4 was ambulating up and down the hallway and in another resident's room on the unit. A unit assistant (UA) was located in the dining room, left to assist Resident #4 into the dining room and offered her cookies. Resident #4 was unable to sit or participate in the activity. While unit assistant was in the dining room [ROOM NUMBER] other residents were present in the hallway and came to join the activity. No staff were present while they were in the hallway. When interviewed on 1/8/2018 12:20 PM UA #6 stated prior to the incident Between Resident #4 and 7, Resident #7 had stated she did not want Resident #4 in her room as she was afraid of her. She was unable to recall who she reported that information to. She was asked to remove Resident #4 from Resident #7's room and was unable to recall who made that request. When she entered the room Resident #7 was steering resident #4 from behind towards the door, she did not witness what occurred next as she was leaving to get help when both residents fell to the floor. Resident #7 did sustain some bruising after the incident. She understood a stop sign was placed on Resident #7's door way and she did not know if that was effective. When interviewed on 1/8/2018 at 12:52 The Director of Social Work stated she followed up on incident within 24 to 28 hours after they occur. She monitors residents after altercations for distress and mood and observed interactions. She was aware of Resident #4's altercations with Resident #10, 5 and 7. Interventions were initiated for monitoring and redirection. A stop sign was added to Resident #7's doorway and for residents that do not have stop signs Resident #4 does not wander in those rooms. She defined monitoring as watching residents and their interactions. When interviewed on 1/9/2018 at 7:45 AM The Director of Nursing (DON) stated the facility incident reports were completed on the unit and reviewed during the morning meeting with the disciplinary team. New interventions for residents were discussed and initiated after the meeting. When a resident to resident altercation occurred she and the Administrator were notified at the time of the incident and immediate interventions were initiated. The CP was updated by the social worker or her and new interventions were added unless it was a medication review. When resident to resident occurred, the staff monitored from the doorway if a resident was in the room and they were to maintain a safe distance between residents. Hall monitoring consisted of staff, when available, to have eyes on the residents involved in the altercation however that did not always occur as staff needed to provide care for other residents. When Resident #5 became more mobile he became more combative with care. A male care giver was initiated to help however that was not always possible and did not always work. Interventions for safety of other residents was staff to monitor the hall. She had not observed any issue with the resident and his roommate. If Resident #3 was in the dayroom with another resident her expectation of staff was to monitor the residents in close proximity, staff would stand in the room for a period of time and then complete safety checks every 2 hours and attempt hourly checks. There was no documented evidence the checks were completed every 2 hours. When interviewed on 1/9/2017 at 8:27 AM, the Administrator stated she was made aware of all resident to resident altercations and was aware she had multiple resident to resident altercations incidents occur in the facility. The incidents that the facility felt were reportable to the New York State Department of Health (NYSDOH) were incidents that identified an intent to harm. Actions taken for protection of other residents after altercations were to review the incident/accident report with a multidisciplinary approach, review behavior notes and have social services and medical follow up with the resident. She monitored for potential abuse by providing training to the staff, increase activities, looking at the time of the incident, pay attention to supervision and use Unit Assistants to meet some resident needs. There was no documented evidence to support the residents were supervised or continually monitored by staff to prevent abuse from occurring after the above incidents occurred and while interventions were initiated or reviewed. 3) Resident #5, Age 88, Date of Admission 8/2/2017, Significant [DIAGNOSES REDACTED]. The MDS dated [DATE] did document the resident had physical behaviors towards others. The psychiatric progress note dated 9/1/2017 documented Resident #5's aggression appeared to decrease when his wife ambulated with him or if the staff showed him his wife was not in the facility. No recommendations were made at that time. He was seen again on 11/3/2017 for increased behaviors and aggression. He had been moved to another unit and both psychiatric provider and the resident were in agreement with the move. No recommendations to decrease his behaviors were made. The nurse practitioner (NP) progress note dated 11/7/2017 documented Resident #5 was admitted to the facility on ,[DATE] from a group home in the community for increasing behaviors. The resident had noted behaviors that were well controlled at that time. His medications were reviewed and he received [MEDICATION NAME] (antidepressant) 30 milligrams (mg) and [MEDICATION NAME] (used to manage dementia) 5 mg for his behaviors. He was easily redirected and he had a psychiatric consult in place and the NP would follow his recommendations. The comprehensive care plan (CCP) dated 11/29/2017 documented the resident had the potential to be a victim of abuse due to his [DIAGNOSES REDACTED]. On 11/29/2017 he had an altercation with Resident #3. The intervention was to put a stop sign in front of his door at all times to deter others from entering. On 12/26/2017 the resident had an altercation with Resident #3, the goal remained the same. New interventions were to observe the resident when awake or in the hall and when he was interacting with others. -The incident /accident report dated 10/16/2017 at 9:10 PM documented Resident #5 had an altercation with Resident #4. Resident #5 was witnessed pushing Resident #4 out of his room. His CP did not trigger for abuse towards others documented upon admission and was now documented. Interventions included redirect, distract, offer fluids, snacks ambulate as allowed and attempt to maintain a safe distance from other residents. Conclusion documented to monitor, document and report behaviors, assess and anticipate his needs, stop sign placed over doorway and when he became agitated intervene before escalation. No injuries were identified. -The incident/accident report dated 11/2/2017 at 7:30 AM documented a CNA #6 heard yelling and found Resident #5 holding Resident #4 against the wall by her arms, when redirection was attempted he became aggressive towards CNA #6. The resident was redirected towards his room. No injuries were noted at that time. Resident #5 had increased anger and aggression towards female residents on the unit and was moved to an all men's behavioral unit. -The incident/accident report dated (MONTH) 8, (YEAR) at 4:39 AM documented Resident #5 was believed to have struck Resident # 6. Resident #6 entered the hallway yelling security and stated he had been assaulted by Resident #5. The residents were separated and assessed for injury. Resident #6 had 2 scratches on his right neck, a bruise to the left scapula and there was blood noted on Resident #6's sheet. The conclusion of the incident was both residents were assessed to be a victim of abuse, family and medical were notified of the incident and there was to be an interdisciplinary meeting to discuss the possibility of a room change as the residents were currently roommates. Resident #6 was moved to another room across the hall. The nursing progress notes documented as follows: -8/29/2017 at 10:13 AM Resident #5 was banging on doors attempting to leave, striking out against staff, stating he would kill who ever tried to stop him. Daughter talked to resident and he calmed. -9/5/2017 at 6:33 Resident #5 was banging on the doors causing them to separate, he was crying and difficult to console or redirect. -10/16/2017 at 9:30 PM, Resident #5 had an altercation with Resident # 4. He was heard yelling at Resident #4. Resident #5 grabbed and pushed Resident # 4 out of his room. -10/25/2017 Resident #5 trying to punch staff. -10/26/2017 Resident punched staff in the chest while she was assisting another resident. -11/2/2017 Resident #5 had another resident up against the wall in the dining room and when redirection was attempted he hit the CNA. The resident was moved to another unit -11/8/2017 Resident # 5 assaulted resident #6 The Social Work progress note dated 11/2/2017 documented interdisciplinary team met to discuss moving the resident to the men's behavioral unit due to his behaviors. Moved from 362 A to 225 B on that date. On 11/8/2017 an altercation triggered by people being in his personal space. Room changed from 225 to 228 with another room mate. On 11/9/2017 Resident #5's cholesterol medication was discontinued on 11/6/2017 as the possible cause of his behaviors and on 11/9 his [MEDICATION NAME] medication was increased to 10mg. Resident #5 was observed on 1/2/2018 on unit 2 in room [ROOM NUMBER]. The room was located across the hall and 2 doors up from Resident #3. A stop sign was across his door way. He was interviewable with some confusion and did not have any issues to report. His roommate was present in the room. Resident #6 was observed on 1/2/2018 at 9:23 AM ambulating in the hall. He was well groomed, had a stop sign over his door to prevent others from entering. He did not recall the incident between him and Resident #5. When interviewed on 1/2/2018 at 11:15 AM, CNA #2 stated she had provided care for both Resident #5 and 6. Resident #5 required mild supervision, staff were to maintain knowledge of his whereabouts and he was on 2 hour checks. Resident #6 required a lot of oversight as he was a new resident, was very confused and scared. The residents were roommates prior to the incident on unit 2. On 11/8/2017 Resident #5 and Resident #6 were involved in an altercation. She witnessed Resident #6 running down the hall. Resident #5 reported Resident #6 was getting into his personal items which was common for him. Resident #6 had blood on his face with visible injuries. She intervened and directed Resident #5 back to his room and Resident #6 in the dining room. She was the only CNA on the locked unit at that time. RN # 4 was made aware of the incident by another CNA that was entering the locked unit and she was unable to recall who RN #4 had a staff member stay in the hall the remainder of the shift to ensure the residents were safe and that became part of the residents plan of care. No specific s

Based on observation, record review and interview conducted during the extended survey, it was determined the facility failed to ensure the 188 residents at the facility were in an environment free of accident hazards, as they failed to implement fire prevention measures and corrective action following an earlier heating unit malfunction incident in a resident room when the fire department responded in January 2014. Specifically, the fire department had to report to the facility at least twice in a 3 month period, due to malfunctioning heating units. Since that time, the facility failed to implement an effective, an ongoing, preventative maintenance program to adequately maintain the heating units free of accumulation of dust and debris to minimize the risk of fire. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of the facility's 188 residents, staff, and visitors. The Immediate Jeopardy was removed on 8/22/2014, prior to the survey exit. Findings include: A previous incident in October 2013 recertification survey identified lack of thorough investigation and reporting to Department of Health (DOH) of a heater fire in a similar unit. A facility life safety report documented there was an incident in resident room 309 on 1/2/2014 at 1:00 AM. An incident accident report documented the heating unit in resident room 309 had a malfunction, causing a strong odor to be emitted from the heating unit. The summary documented the fire alarm was pulled and the fire department responded. The summary documented the policies and procedures were reviewed and no changes were required. The report documented heating units were maintained and audited on a maintenance schedule. During observations made on the building inspection tour, on 8/20/2014 between 10:30 AM and 10:50 AM, these specific heating units were observed in 19 (rooms 301-302, 305, 307-308, 311-314, 317, 319-320, 323, 353, 355, 358-360, and 363) of the unit's 40 rooms. When the surveyor sampled 6 resident rooms (302, 308, 313, 314, 358, and 359) they were observed to contain significant dust build up around the filter assembly and inside the unit. At 10:52 AM, a surveyor had a maintenance staff member remove the front cover of the the heating unit in resident room 358 to verify preventative maintenance was conducted on the unit. Significant visible dust/lint build up along the sides of the unit, on the motor, and inside the blower cage assembly attached to the motor was observed. At 1:55 PM, the Director of Environmental Services was interviewed regarding the preventative maintenance conducted on the heating units. He stated preventative maintenance was conducted usually every 4 months in January, May, and September, and included cleaning the filters, specific heating units were approximately 42-[AGE] years old. He stated all units were checked after the incident in January and nothing was found. He stated these heating units were very basic and usually the fan motor failed on the heaters. On 8/20/2014 between 2:06 PM and 2:35 PM, the surveyor and the Director of Environmental Services observed the following: - The heating unit in resident room 359 contained significant dust/lint buildup on the exterior unit cover, the motor, and in the blower cage assembly attached to the motor. At the time of the observation, the Director of Environmental Services stated this was about average dust buildup and that the dust buildup did not pose a fire hazard. He stated the units would be cleaned in a couple of weeks. - The heating unit in resident room 302 contained significant dust/lint buildup on the interior unit sides, the motor, and the blower cage assembly attached to the motor. - The heating unit in resident room 301 contained significant dust/lint buildup on the interior unit sides, the motor, and the blower cage assembly attached to the motor. - The heating unit in resident room 311 contained significant dust/lint buildup on the interior unit sides, the motor, and the blower cage assembly attached to the motor. - The heating unit in resident room 320 contained significant dust/lint buildup on the interior unit sides, the motor, and the blower cage assembly attached to the motor. - The heating unit in resident room 323 contained significant dust/lint buildup on the interior unit sides, the motor, and the blower cage assembly attached to the motor. On 8/20/2014 at 3:20 PM in an interview with the Administrator, he stated there were conflicting statements regarding the 1/2/2014 incident regarding smoke. He stated the heater unit fan motor burned up or had rather seized up. He stated there was no smoke or fire and the odor was burnt oil. He stated the fire alarm was activated and the fire department responded. He stated the units were audited by maintenance and were cleaned either quarterly or on a trimester schedule. He stated there were about 6-10 of these specific heating units currently in service. He stated Preventative maintenance verified the unit was operational, was checked for dust around components and vacuumed as needed. The preventative maintenance log and the policy/procedure manual were requested. On 8/20/2014 at 3:48 PM, during an interview with the Director of Environmental Services, he stated there is no written policy/procedure/directives on how to perform preventative maintenance on these specific heating units and no preventative maintenance log was provided. On 8/20/2014 at 3:50 PM in an interview with a maintenance staff member, he stated preventative maintenance was conducted on the these heating units. He stated he pulled the covers, vacuumed out the unit using various brushes, washed the filter or replaced the filters as needed on the these heating units. He stated preventative maintenance was last conducted on the units in May and usually completed every 4 months. He stated the facility buffed the floors regularly and the process created a lot of dust. He stated the these heating units were only present on the third floor. He stated the incident in early January was caused by the motor getting really hot. On 8/20/2014 at 4:00 PM, one of these specific heating units was observed by a surveyor and the maintenance staff member in resident room 301. He stated the unit contained typical dust buildup and sometimes the filter dropped out of the bottom of the unit and allowed dust to accumulate on the motor and interior part of the unit. He stated the dust buildup could pose a fire hazard. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 8/22/2014 based on the following corrective actions taken by the facility: - Implemented a fire watch (make scheduled rounds visually inspecting areas for signs of smoke and/or fire) for all rooms containing these older heating units. - Developed a system to adequately maintain and monitor facility heating units. - Educated facility maintenance staff on proper preventative maintenance procedures for these specific heating units. - Ensured the heating units were free of accumulated dust/lint buildup to reduce the risk of fire. - Educated the majority of facility staff on roles and responsibility regarding the facilities fire safety procedure and ensured remaining staff would be trained prior to returning to duty. - Revised policies and procedures to address maintenance of these older heating units. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. 10NYCRR 415.12 (h)(1)(2)

Based on observation, record review and interview conducted during the extended survey, it was determined the governing body failed to ensure the facility implemented fire prevention measures and corrective action following at least 2 heating unit malfunctions that lead to the fire department onsite response. Specifically, the fire department had to respond to the facility at least twice in a 3 month period due to malfunctioning heating units that were approximately [AGE] years old. The governing body failed to ensure their preventative maintenance policies were developed and properly implemented to reduce the fire risk from the remaining heating units. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of the facility's 188 residents, staff, and visitors. The Immediate Jeopardy was removed on 8/22/2014, prior to the survey exit. Findings include: A previous incident in October 2013 recertification survey identified lack of thorough investigation and reporting to Department of Health (DOH) of a heater fire in a similar unit. A facility life safety report documented there was an incident in resident room [ROOM NUMBER] on 1/2/2014 at 1:00 AM. The report documented the heating unit in resident room [ROOM NUMBER] malfunctioned, resulting in the fire alarm being pulled and the fire department responding. The report documented heating units were audited on a maintenance schedule. During building observations on 8/20/2014 between 10:30 AM and 10:50 AM, heating units in resident room [ROOM NUMBER], 308, 313, 314, 358, and 359 were observed to contain significant dust build up around the filter assembly and inside the unit. When the Director of Environmental Services was interviewed on 8/20/2014 at 1:55 PM, he stated these specific heating units were approximately 42-[AGE] years old and that he preventative maintenance was conducted on the units usually every 4 months. During an interview with the Administrator, on 8/20/2014 at 3:20 PM, he stated the fire alarm was activated and the fire department responded for the October 2013 and the January 2014 incidents. He stated these heating units were audited by maintenance and cleaned either quarterly or on a trimester schedule. He said he believed there were about 6-10 specific heating units currently in service. He stated preventative maintenance was supposed to verify the heating unit was operational, was checked for dust around components and vacuumed as needed. The Administrator also stated he was trying to create a budget to replace these older heating units. On 8/20/2014 at 3:48 PM, in an interview with the Director of Environmental Services, he stated there was no written instrument on what do when performing preventative maintenance on these specific heating units. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 8/22/2014 based on the following corrective actions taken by the facility: - Implemented a fire watch (make scheduled rounds visually inspecting areas for signs of smoke and/or fire) in rooms containing specific heating units. - Developed a system to adequately maintain and monitor facility heating units. - Educated facility maintenance staff on proper preventative maintenance procedures for heating units. - Ensured the heating units were free of accumulated dust/lint buildup to reduce the risk of fire. - Educated the majority of facility staff on roles and responsibility regarding the facilities fire safety procedure and ensured remaining staff will be trained prior to returning to duty. - Revised policies and procedures to address maintenance of specific heating units. heating units. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. 10NYCRR 415.26(b)(2)(3

Based on record review and staff interview conducted during the extended survey, it was determined the facility's quality assessment and assurance (QA) committee failed to readily and effectively identify issues that had the potential to cause serious harm to the health and safety of residents for the 188 residents, staff and visitors in the facility. Specifically, after the fire department responded twice in a 3 month period, the facility's QA committee failed to develop and implement an appropriate plan of action to address the lack of effective preventative maintenance for their [AGE] year old heating units to reduce the immediate risk of fire injury. This resulted in no actual harm with potential for serious harm that is immediate jeopardy to the health and safety of all its residents. The Immediate Jeopardy was removed prior to exit on 8/20/2014. Findings include: An incident accident plan documented a previous incident occurred in 10/2013 with a heater fire in a resident room and another incident on 1/2/2014 with the heating unit in resident room [ROOM NUMBER]. For the incident on 1/2/2014, the report documented the heating unit malfunctioned. The report documented policies and procedures were reviewed, with no changes required, and the heating units were maintained and audited on a maintenance schedule. (Refer to F323.) During an interview with the facility Administrator on 8/20/2014 at 5:18 PM, he stated he was unaware of on going issues with the heating units such as significant dust build up in the heating units and this should have been addressed in QA. He stated the maintenance department was supposed to be tracking the issue. The Administrator said he had not asked for the audits and these were not discussed in QA. He stated the facility should have been doing weekly rounds on the heating units, instead of the scheduled every 4 months. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 8/22/2014 based on the following corrective actions taken by the facility: - Developed a system to adequately maintain and monitor facility heating units. - Educated facility maintenance staff on proper preventative maintenance procedures for the facility's heating units. - Policies and procedures were revised to address maintenance of specific heating units. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. 10NYCRR415.27(a-c)

Based on record review, observation, and interviews conducted during the standard survey it was determined the facility did not ensure for 1 of 9 residents (Resident #3), reviewed for self determination, had the right to refuse treatment. Specifically, Resident #3 was repeatedly catheterized against her wishes, medicated with anti-anxiety medication when she became agitated. This resulted in actual harm for Resident #3 that is not immediate jeopardy. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 4/16/2014, documented the resident's cognition was moderately impaired, her ability to be understood and understand others was intact, and she was continent of bowel and bladder. The licensed practical nurse's (LPN) progress note, dated 5/30/2014, documented the resident was continent of bowel and bladder and ambulated to the bathroom ad lib with a walker. The physician's orders [REDACTED]. The nursing progress note, dated 6/3/2014 at 10:05 PM, documented the resident "firmly refused to be catheterized". The importance of the procedure was explained to the resident 3 times and the resident "still refused". The next shift was to follow up on the order. The nursing progress note, dated 6/6/2014 at 6:31 AM, documented the resident was catheterized for sterile urinalysis, culture and sensitivity. The nursing progress note, dated 6/9/2014 at 1:15 AM, documented the resident was positive for Escherichia Coli (E-Coli, bacteria) with Extended-Spectrum Beta-Lactamases (ESBL, highly resistant organisms), was put on contact isolation precautions, and instructed to use the bedside commode. The resident was found using the bathroom and reeducated to use the bedside commode. The note did not document the resident was incontinent. The registered nurse (RN#3) Manager's progress note, dated 6/10/2014 at 4:22 PM, documented the resident had E-Coli positive for Extended-Spectrum Beta-Lactamases (ESBL, highly resistant organisms) in the urine. The resident was on [MEDICATION NAME] treatment with [MEDICATION NAME], was asymptomatic, had intermittent bladder incontinence, and was non-compliant with contact isolation precautions. She documented as a recommendation the resident have an indwelling Foley catheter temporarily while [MEDICATION NAME] treatment was ongoing and until ESBL in the urine was resolved. The physician's orders [REDACTED]. -insert indwelling Foley catheter for infection precautions and incontinence, -contact isolation for positive ESBL in the urine, -[MEDICATION NAME] tablet 1 gram (g) (a urinary antiseptic drug) two times a day for [MEDICATION NAME] for UTI, and; -vitamin C tablet 500 mg two times a day for supplement. The nursing progress note, dated 6/10/2014 at 8:34 PM, documented the resident refused to have a Foley catheter and was "educated" that she would be confined to her room for refusing the catheter. The resident continued to refuse the catheter and staff were to "continue to monitor". Nursing progress notes, dated 6/11/2014 at 3:51 PM and 9:47 PM documented the resident had an elevated temperature and was started on [MEDICATION NAME] (antibiotic) for a UTI, and the resident continued to refuse the catheter. The nursing progress note, dated 6/12/2014 at 5:14 PM, documented the resident had an indwelling Foley catheter for "incontinence" and contact isolation precautions. The nursing progress notes, dated 6/14 at 12:45 PM, 6/15 at 2:45 PM, 6/16 at 12:59 PM, 6/17 at 1:17 PM, 6/18 at 2:09 PM and on 6/19/2014 at 1:55 PM, documented the resident stayed in her room the entire shift. The Minimum Data Set (MDS) assessment, dated 6/16/2014, documented the resident's cognition was moderately impaired, her ability to be understood and to understand others was intact, and she had an indwelling catheter. The Medication Administration Record [REDACTED]. The nursing progress note, dated 6/19/2014 at 11:10 PM, documented "the resident stated she was going to rip out her Foley catheter." The nursing progress note, dated 6/26/2014 at 6:40 AM, documented the resident took her Foley apart and threw it across the room. The nursing progress note, dated 6/26/2014 at 1:58 PM, documented the resident had her Foley out, urine was all over the floor, and the resident was refusing care. A physician's orders [REDACTED]. The nurse practitioner's note, dated 6/26/2014, documented the resident attempted to pull her Foley out last evening and had some blood tinged urine due to "trauma." The physician's orders [REDACTED]. The nursing progress note, dated 7/6/2014 at 3:46 AM, documented the resident wanted the Foley catheter removed. The nursing progress note, dated 7/21/2014 at 9:59 PM, documented the resident's Foley catheter was found on the floor in the resident's room, the resident stated she did not know how it came out, and the resident refused to have another catheter inserted. The nursing progress note, dated 7/21/2014 at 11:48 PM, documented the resident was educated on the importance of the Foley catheter and taking [MEDICATION NAME]. A 22 F Foley catheter with a 30 cc (cubic centimeter) balloon was inserted as the nurse thought a bigger catheter was needed because the previous "just fell out". During an interview, on 8/21/2014 at 2 PM, the resident stated she could not remember how long she had the catheter. She stated she did not want it, and did not know why she had it. She stated it was hard to walk around with it and stated it looked dirty. She further stated she wished she did not have a catheter. During an interview on 8/25/2014 at 11:20 AM, the CNA stated the reason the resident had a Foley catheter was for contact precautions. She stated the resident was incontinent and had an infection in the urine. She further stated the resident had been continent, and used the bathroom on her own, until a recent illness when a catheter was started to contain the infected urine. During an interview on 8/25/2014 at 11:40 AM, the RN Manager stated if the resident refused the Foley catheter, it was not "ok" to threaten isolation. During an interview on 8/26/2014 at 9:05 AM, the resident's physician stated Foley catheters were not used for infection control purposes; he thought the resident came from the hospital with the Foley and he was planning to discontinue it. 10NYCRR 415.3 (e)(1)(ii)

Based on observation, record review, and interview conducted during the standard survey, it was determined the facility did not allow 1 sampled resident (Resident #5) and 3 residents outside the sample (Residents #30, 31, and 32) the right to exercise his or her autonomy related to smoking. Specifically, Residents #5, 30, 31 and 32 were not offered the opportunity to continue smoking during a transition to a totally smoke free facility after 4/1/2014. This resulted in actual harm that is not immediate jeopardy for Resident #5, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #30 and 31. Findings include: 1) Resident #5 had [DIAGNOSES REDACTED]. The Smoking assessment dated [DATE] documented the resident was a safe smoker, required supervision with the smoking schedule, lighting the cigarette, understood the rules and was aware of the designated smoking area. The smoke free facility memo, dated 12/31/2013, documented the facility would transition to a smoke free facility on 4/1/2014 and residents would no longer be able smoke on facility grounds. The note documented the social worker or administrator would be available for questions and smoking cessation would be offered if the resident was interested. The Social Worker note dated 1/20/2014 documented the resident was informed of the new smoking policy for the facility beginning 4/1/2014. The resident's comprehensive care plan (CCP), dated 4/25/2014 and updated 7/15/2014, documented to keep the resident's routine consistent and respect leisure lifestyle choices. The CCP did not document on smoking. The Social Worker note dated 2/3/2014 documented the resident requested the smoking times be posted. The note documented the resident was reminded of the up coming smoking policy change effective 4/1/2014. The Social Worker note dated 5/5/27/2014 documented the resident no longer smoked, had recently lost weight and was slowly adjusting to not being able to smoke. The note did not document smoking cessation. The resident's Minimum Data Set (MDS) assessment, dated 7/4/2014, documented the resident was cognitively intact, and required supervision when off the unit. During an observation on 8/21/2014 at 12:52 PM, the resident asked the CNA for a cigarette. The CNA stated "I don't smoke". The resident turned and walked away. During an interview on 8/20/2014 at 2:00 PM, the licensed practical nurse (LPN) stated she was aware of the current smoking policy and stated "this is a non smoking facility and thank god that's over with." She stated the resident was offered the patch for smoking cessation and refused. She stated the resident continued to request cigarettes a couple times a week. On 8/22/2014 at 9:37 AM in an interview with the Director of Environmental Services, he stated the smoking policy had changed and it is now a smoke free campus. He stated no resident can smoke on facility property, as smoking was eliminated for all. He stated friends or family can take residents off the property to smoke. He stated he was unsure of the exact date when the policy changed and there were approximately 15-20 smoking residents. During an interview on 8/25/2014 at 2:23 PM, the certified nurse aide (CNA) stated the resident was aware of the new smoking policy. She stated "he still carries money with him and requests to smoke every day". She stated when the policy was instituted, the resident had some behaviors and she did not know if smoking cessation was offered to him. During an interview on 8/26/2014 at 8:17 AM, the registered nurse (RN) Unit Manager stated the current policy for smoking was residents could smoke, if the family provided the materials and accompanied the resident off the property. She stated the resident frequently requested to smoke. During a interview on 8/26/2014 at 10:30 AM, the Director of Social Work stated the no smoking policy became effective 4/1/2014. She stated the resident could continue to smoke off the property, if accompanied by family however the resident did not have family. She stated the residents who smoked received a letter, were offered interventions, and psychological services. She stated the resident was a safe smoker and continued to focus on smoking. 2) Resident #30 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) review dated 3/6/2013 documented the resident enjoyed smoking times and talking to friends on the telephone. The smoking care plan documented the resident was a safe smoker who complied with house policies. The CCP review dated 10/16/2013 documented the resident continued to enjoy smoke time and talking on the phone. The Safe Smoking Evaluation dated 1/23/2014 reported the resident was safe to smoke supervised and she was quoted as saying "I am upset, my right is to smoke". The CCP was updated on 4/1/2014 with monitored smoking status discontinued. The Minimum Data Set (MDS) assessment dated [DATE], documented independence in daily decision making. The Staff Assessment of resident mood documented little interest or pleasure in doing things, feeling or appearing down, depressed or hopeless, and being short-tempered, easily annoyed nearly every day. The recreation quarterly progress note dated 7/6/2014 documented the resident used to go outside for smoking which is no longer available after policy change. The psychology consult note dated 7/14/2014, documented refusal to get out of bed and resident statements of unhappiness with placement and wanting to go home. During and interview with CNA #3 on 8/25/2014 at 2:50 PM, she stated the resident was very angry about being unable to smoke. It was the only time she would get out of bed, and since the change, she has gotten up out of bed much less often. 3) Resident #31 had [DIAGNOSES REDACTED]. The comprehensive care plan updated 4/2/2013, documented the resident was a supervised smoker and adhered to smoking policies. The psychology consult note dated 1/18/2014, documented the resident was referred because he is angry over the no smoking policy effective 4/1/2014 and has been refusing medications and fingersticks. The social service progress note dated 1/20/2014, documented the resident was informed of the non-smoking policy going into effect 4/1/2014 and was not interested in getting help to quit. He was very angry about not being able to smoke. The social service progress note dated 2/27/2014, documented the resident was more sarcastic and mean spirited and could be quite rude to others in the facility. The psychology consult note dated 2/5/2014, documented the resident's refusal to take mediations and anger over the change in the smoking policy. The Minimum Data Set (MDS) assessment dated [DATE], documented memory intact, verbal and other behavioral symptoms occurring regularly, and independence with most ADL's. During an interview with CNA #3 on 8/25/2014 at 2:50 PM, she stated the resident has become more verbally inappropriate since not being able to smoke. 10NYCRR 415.5(b)(1-3)

Based on observation, record review and interview conducted during the post survey revisit, it was determined the facility did not allow 5 of 5 sampled residents (#4, 13, 14, 15, and 16) the right to exercise their autonomy related to smoking. Specifically, Residents #4, 13, 14, 15 and 16 were not provided the opportunity to continue smoking during the transition to a totally smoke free facility after 4/1/2014. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY FROM THE 8/26/2014 SURVEY. Findings include: During the interview with the Director of Social Work during the post survey revisit on 11/3/2014 at 4:50 PM, she stated 19 residents were on the list as smokers who were "grandfathered". She stated corporate set up the documentation completed for the electronic care plan. The Director stated the documentation for the comprehensive care plan (CCP) was recently changed to no longer state the residents were smoking off the property. The social worker stated she was initially told the resident had to go off the property to smoke. The Director said no residents were smoking at this time and did not know when they would be allowed to smoke. The Director of Social Work stated administration needed to make the decision regarding the procedure that would be followed. She said the residents would be told when they would be smoking again when there was a definitive timeframe. She stated it was also her understanding that a resident could light his/her own cigarette and smoke safely, they would be allowed to do so. 1) Resident #13 has [DIAGNOSES REDACTED]. A smoking evaluation, completed by the administrator on 10/2/2014, documented the resident did not have any cognitive loss or visual deficit or dexterity problems. The resident smoked 5 to 10 times per day and liked to smoke morning, afternoon, evenings and nights. The resident was not able to light his own cigarette and required supervision and one on one assistance. A plan of care was initiated to assure the resident was safe while smoking. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, ambulated independently, and required supervision when off the unit and with eating and personal hygiene. A nurse practitioner's progress note dated 10/10/2014 documented the resident was seen on this date for smoking cessation as the resident was "grandfathered into the no-smoking policy" and had been "re-allowed to smoke". The resident requested to go out to smoke stating this was all he had to look forward to throughout the day. The resident was offered alternatives to smoking and declined them, stating he "would like to go out to smoke". On 10/16,/2014, the occupational therapist (OTR) documented the resident was referred to determine the resident's safety and independence with activities of daily living (ADLs) or smoking due to the resident's need for assistance due to his medical condition and decreased cognition. The resident stated "I want to smoke a cigarette out back". The OTR documented the resident's fine motor skills, upper extremity strength and balance were within normal limits. Due to the resident's [DIAGNOSES REDACTED]. The resident exhibited the ability to light a cigarette, ability to put the cigarette out and knowledge of when the cigarette "should be put out". A social work progress note dated 10/22/2014 documented the social worker spoke with the resident and he continued to want to smoke when able to and accommodations would be made. The comprehensive care plan (CCP) initiated 10/22/2014 and revised on 11/3/2014 documented the resident was a "grandfathered smoker" and "will be given the opportunity daily to smoke off" the property with appropriate staff supervision. During an interview on 11/3/2014 at 1:45 PM with the registered nurse (RN) manager responsible for units 2 north and south, he stated not all the smoking assessments had been completed as far as he knew. He said once completed, the residents will be able to smoke and as of this time, "no one has gone out to smoke yet". During an interview on 11/3/2014 at 2:20 PM with a licensed practical nurse (LPN) on the resident's unit, she stated Resident #13 had been requesting to smoke "more now that they interviewed him". During the interview with the Director of Social Work during the post survey revisit on 11/3/2014 at 4:50 PM, she stated she was aware Resident #13 frequently mentioned wanting to smoke. 2) Resident #14 had [DIAGNOSES REDACTED]. A smoking assessment completed 10/14/2013 documented the resident was able to safely smoke, was not able to safely extinguish her cigarette, understood the smoking rules, did not burn holes in her clothing and was alert and oriented. The resident needed assistance lighting her cigarette, needed direct supervision and followed the smoking schedule, "per policy". The current Minimum data Set (MDS) assessment dated [DATE] documented the resident had good short and long term memory and was independent in decision making. During the assessment period, the resident did not transfer, ambulate or move from her bed. She ate with supervision and needed total assistance with dressing and personal hygiene. A nurse practitioner's (NP) note dated 10/10/2014 documented the resident was seen for smoking cessation as the resident was allowed to smoke again "as she is being grandfathered" into the facility's no smoking policy. The NP documented she spent extensive time with the resident discussing smoking cessation and the resident was "refusing this at this time". The resident was requesting to continue to smoke "as it is the only time she does come out of her room during the day". The ramifications of the long term effects of smoking, including her past history of a stroke and the chances of a recurrent stroke, were discussed and the resident continued to refuse smoking cessation and requested to smoke. The occupational therapy (OTR) assessment dated [DATE] documented the resident was referred due to nursing's concern about safety with smoking tasks due to the resident's [DIAGNOSES REDACTED]. The OTR documented the resident rarely got out of bed, per nursing. The resident's fine motor coordination and gross motor coordination were intact, and sensory processing was intact. Due to the resident's [MEDICAL CONDITION], the resident was assessed to need minimum assistance with all smoking tasks: lighting cigarette and putting out the cigarette, to prevent burning/injury and for safety awareness. On 10/22/2014 a social work progress note documented the resident was offered smoking cessation and the resident continued to want to smoke when able to do so and, accommodations would be made. On 11/3/2014 a smoking evaluation was completed by the Activities Director and documented the resident smoked 2 to 5 times a day and liked to smoke in the morning, afternoon, evenings and nights. The resident was documented as needing a smoking apron, supervision and one on one assistance. Per the evaluation, a plan of care was not initiated. The comprehensive care plan (CCP) revised on 11/3/2014 documented the resident had a history of [REDACTED]. The resident would not be able to smoke safely in the designated area and would be educated and offered smoking cessation options. There was no further documented rationale related to the decision for the resident to no longer be allowed to smoke. During an interview with Resident #14 on 11/3/2014 at 12:20 PM, she stated she had been told she could smoke and "has asked staff to take her across the street to smoke and they would not do it." She stated they will not let her smoke. During the interview with the Director of Social Work during the post survey revisit on 11/3/2014 at 4:50 PM, she stated Resident #14 would probably start coming out of her room more often once allowed to smoke. She did not state whether Resident #14 was going to be allowed to smoke. 3) Resident #16 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and was independent in all activities of daily living. A nurse practitioner's note dated 10/10/2014 documented the resident was seen for smoking cessation as she was grandfathered into the no smoking policy at the facility and was going to be allowed to smoke. The resident declined smoking cessation and requested to smoke. She threatened to transfer to a different facility if she was not allowed to smoke. An occupational therapy evaluation was completed on 10/14/2014 related to the resident's request to smoke. The OTR documented nursing had questions about the resident's safety secondary to her diagnoses. The resident was assessed to have intact fine and gross motor coordination, sensory processing was intact and visual spatial perceptual skills were intact. The resident was documented to have "full independence with all ADLS (activities of daily living). The resident had normal/good fine motor skills and strength in order to participate in smoking activities. The resident was documented to be at risk for behavioral outbursts and depression. On 10/22/2014 social services documented in a progress note, the resident was offered smoking cessation and continued to want to smoke when able to do so and noted "accommodations will be made". The comprehensive care plan (CCP) initiated on 10/22/2014 documented the resident was a grandfathered smoker and would be given the opportunity daily to smoke off the facility property with appropriate staff supervision. 10NYCRR 415.5(b)(1-3)

Based on record review, observation and interview conducted during the standard survey, it was determined for 3 of 6 residents (Residents #8, 14 and 18) reviewed for pressure ulcers, the facility did not ensure necessary treatment and services were provided to promote healing. Specifically, Resident #14's pressure ulcer was not assessed timely; the pressure ulcer treatments were not consistently provided; and the pressure ulcer increased in size and worsened from a Stage II to a Stage III. Resident #18 did not receive pressure ulcer treatment as ordered by the physician; and Resident #8's Stage IV pressure ulcer was left uncovered/exposed for a prolonged period of time. This resulted in actual harm to Resident #14, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #8 and 18. Findings include: 1) Resident #14 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 6/25/2014, documented the resident's cognition was severely impaired; the resident required extensive assistance for bed mobility and was totally dependent with transfers. The MDS documented the resident did not have any pressure ulcers and was at risk for developing pressure ulcers, with interventions that included turning and positioning and pressure reducing devices to the bed and the wheelchair. A physician order [REDACTED]. On 7/4/2014 at 1:37 PM, a "verbal" physician order [REDACTED]." The order was "confirmed by" an licensed practical nurse (LPN). There was no documented evidence in the medical chart the "open area" was assessed by a qualified licensed professional (registered nurse, physician). A facility acquired pressure ulcer investigation, dated 8/5/2014, documented the resident had a Stage II pressure ulcer on her coccyx, measuring 1.8 cm (centimeters) x 1.4 cm. The investigation documented the pressure ulcer was previously documented as MASD (moisture associated skin damage). The treatment for [REDACTED]. A nursing progress note dated, 8/6/2014 at 1:48 PM, documented the Xeroform gauze treatment to the coccyx and the moisture barrier ointment to the buttocks were not completed as the resident was out of bed and in her wheelchair. A nursing progress note, dated 8/7/2014 at 1:52 PM, documented the Xeroform gauze treatment to the coccyx and the moisture barrier ointment to the buttocks were not completed as the resident was out of bed. A registered nurse (RN) progress note, dated 8/8/2014 at 3:44 PM, documented the resident had a worsening pressure ulcer on the coccyx, that measured 2.5 cm x 2 cm x 0.2 cm, with yellow slough (dead tissue) in the wound bed. The pressure ulcer stage was not documented. The RN note documented an alternating air mattress was to be implemented to assist with healing. A physician order, dated 8/8/2014, documented to apply wound gel (moisture wound treatment) to the resident's coccyx every day for a Stage III pressure ulcer. A physician order, dated 8/14/2014, documented to discontinue the wound gel treatment and apply Santyl ointment (treatment for [REDACTED]. On 8/14/2014, both the physician wound care specialist's initial evaluation and the resident's initial weekly pressure ulcer assessment record, documented the resident had a Stage III pressure ulcer on the coccyx that measured 3.5 cm x 1.4 cm and 0.3 cm depth, with surrounding [DIAGNOSES REDACTED] (redness). The physician wound care specialist's 8/14/2014 evaluation also documented the pressure ulcer treatment was Santyl, covered with a dry protective dressing applied daily. The evaluation documented the resident had incontinence-associated [MEDICAL CONDITION], which was a new problem, and barrier cream every shift was the treatment. The Director of Nursing (DON) updated the resident's comprehensive care plan (CCP) on 8/14/2014, and documented the resident developed a pressure ulcer on the coccyx. Interventions included: administering treatments as ordered, monitoring for effectiveness, and monitoring the dressing every shift. During a dressing change observation on 8/21/2014 at 1:30 PM, with the physician wound care specialist and registered nurse (RN) #2 both present, the resident's coccyx pressure ulcer was observed to be a Stage III that measured 3.5 cm x 2 cm and 1 cm depth, with necrotic (dead) tissue partially covering the wound bed. The resident had an alternating air mattress on her bed. The wound care specialist evaluation form dated 8/21/2014 documented the resident's Stage III pressure ulcer had not improved and consent was obtained for debridement (removal of dead tissue) of the pressure ulcer. A nursing progress note, dated 8/22/2014 3:03 PM, documented the Santyl ointment treatment to the coccyx and the moisture barrier ointment to the buttocks was not completed, as the resident was out of bed in her wheelchair. The progress note documented the 3-11 PM nurse was made aware. There was no documentation in the medical record the treatment was completed on 8/22/2014 by the 3-11 nurse. During an interview with LPN #1 on 8/25/2014 at 10:20 AM, she stated she tried to get treatments done before the resident got out of bed, but sometimes was unable to. She stated if she did not get a treatment done, she reported to the 3-11 shift nurse. LPN #1 stated she was sure treatments were followed up by 3-11 nurse, because she trusted the nurses on the other shift. During an interview with the RN #1 Manager on 8/25/2014 at 12:15 PM, she stated the first time she assessed the resident's coccyx was on 8/8/2014 when LPN #1 reported the area had worsened. RN #1 stated she reported the pressure ulcer to the physician, obtained an order for [REDACTED]. She stated if the treatment was not completed on the day shift, and was completed by the 3-11 shift, she expected that nurse completing the treatment to document it in the medical record. RN #1 reviewed the resident's record, with the surveyor present, and was unable to find any documented evidence the resident's pressure ulcer treatments were completed by the 3-11 nursing staff. RN #1 stated treatments not completed per order could contribute to worsening of wounds. During an interview with the DON, on 8/26/2014 at 1:10 PM, she stated it was not acceptable for the nurses not to do treatments because the resident was out of bed. She stated she expected the resident be put back to bed for the treatment. 2) Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 6/17/2014, documented to cleanse the resident's sacral pressure ulcer with normal saline, fill the wound with [MEDICATION NAME] AG (antimicrobial wound dressing) and cover it with a [MEDICATION NAME] dressing. The order documented the dressing was to be changed every other day on the day shift. A weekly pressure ulcer assessment record, dated 6/17/2014, documented the resident had a Stage IV pressure ulcer on the sacrum. The pressure ulcer measured 4 cm (centimeters) x 3 cm and 0.8 cm depth. The Minimum Data Set (MDS) assessment, dated 6/25/2014, documented the resident's cognition was intact, required extensive assistance with most activities of daily living (ADL) and was admitted with a Stage IV pressure ulcer. The comprehensive care plan (CCP), dated 7/2/2014, documented the resident had a Stage IV pressure ulcer and interventions included administering medications and treatments as ordered, and monitoring for effectiveness. A weekly pressure ulcer assessment record, dated 7/10/2014, documented the resident had a Stage IV pressure ulcer on the sacrum measuring 2.5 cm x 3 cm x 1.7 cm. A nursing progress note, dated 7/12/2014 at 2:49 PM, documented the resident refused all treatments that day and he was yelling and striking out. The July 2014 treatment administration record (TAR) documented the [MEDICATION NAME] treatment to the sacral pressure ulcer was signed as completed on: July 2, 4, 6, 8, 10, 16, 18, 20, 22, 24, 26, 28, and 30. There was no documented evidence the resident's treatment was done on July 12 and July 14 as ordered. A weekly pressure ulcer assessment record, dated 7/17/2014, documented the resident had a Stage IV pressure ulcer measuring 3 cm x 3 cm x 1.5 cm. A nursing progress note, dated 8/7/2014 at 1:38 PM, documented the [MEDICATION NAME] dressing to the sacral pressure ulcer was not completed, due to the resident being out of bed. A weekly pressure ulcer assessment record, dated 8/7/2014, documented the resident had a Stage IV pressure ulcer on the sacrum debrided (removal of dead tissue) by the wound care doctor. The pressure ulcer measured 2.5 cm x 2 cm x 1.3 cm. A physician order, dated 8/11/2014, documented to cleanse the sacrum with normal saline and pack the pressure ulcer with [MEDICATION NAME] AG and cover with gauze daily. A nursing progress note, dated 8/13/2014 at 4:05 PM, documented the [MEDICATION NAME] dressing to the resident's sacral pressure ulcer had not been completed. A nursing progress note dated 8/13/2014 at 9:45 PM, documented an "as needed" [MEDICATION NAME] dressing was changed to the sacral pressure ulcer due to the dressing being saturated. A weekly pressure ulcer assessment record dated 8/14/2014 documented the resident had a Stage IV pressure ulcer on the sacrum and measured 3 cm x 2 cm x 1.1 cm. A nursing progress note, dated 8/15/2014 at 1:31 PM, documented the [MEDICATION NAME] dressing to the resident's sacral pressure ulcer was not completed due to the resident being out of bed and in his wheelchair. A weekly pressure ulcer assessment record dated 8/21/2014 documented the resident had a Stage IV pressure ulcer on the sacrum and measured 2.7 cm x 2.2 cm x 1.5 cm. During the resident's pressure ulcer dressing change on 8/25/2014 at 9:50 AM with licensed practical nurse (LPN) #1, the resident was observed to have a pressure ulcer on the sacrum, with the wound bed partially covered with dead tissue, and the surrounding skin was white. The August 2014 TAR documented the [MEDICATION NAME] treatment to the sacral pressure ulcer was signed as completed for 11 of the 31 days in August (August 3, 5, 9, 14, 16, 17, 18, 20, 22, 24, and 25.) During an interview with licensed practical nurse (LPN) #1 on 8/25/2014 at 10:20 AM, she stated she tried to get treatments done before the resident get out of bed but sometimes she was unable. She stated if the treatment could not get done, she was sure treatments were followed up by 3-11 nurse, because she trusted them. She stated when the 3-11 nurse did the treatment, it was signed for and documented in the chart. During an interview with the RN #1 Manager, on 8/25/2014 at 12:15 PM, she stated she would expect the day shift nurse to put the resident back to bed to complete the treatment or if the resident was resistive she would expect the nurse would re-approach. She stated if a resident's treatment was completed by the 3-11 shift, she expected it to be documented in the medical record. RN #1 reviewed the resident's record with the surveyor; RN #1 was unable to find any documented evidence that the resident's pressure ulcer treatments were completed by the 3-11 nursing staff except for the date of 8/13/2014. She stated not completing the treatments per order could contribute to worsening of wounds. During an interview with the Director of Nursing (DON) on 8/26/2014 at 1:10 PM, she stated it was not acceptable for nurses not to do treatments because the resident was out of bed. 3) Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 4/24/2014, documented the resident had moderate cognitive impairment, the need for total assistance of two staff with bed mobility, transfers, and bathing. The MDS documented the resident had a Stage IV pressure ulcer, measuring 11 cm (centimeters) x 11 cm with 4 cm of depth, with the presence of slough (moist dead tissue). The comprehensive care plan (CCP), revised on 7/31/2014, documented the resident had a Stage IV pressure ulcer on the coccyx related to immobility, significant weight loss, and poor intake. Interventions included monitoring the dressing every shift to ensure it was attached and adhering, and the need to remind the resident to turn and position at least every 2 hours. The wound consult note dated 8/7/2014 documented the resident's wound was not improved and a cauterization procedure was done for abnormal granulation tissue. Skin monitoring sheets, dated 8/7/2014 to 8/21/2014, documented the resident's coccyx pressure ulcer measured 5.5 cm x 2.4 cm with depth of 1 cm and undermining of 2 cm. Treatment consisted of calcium alginate (special wound dressing to absorb drainage) covered with a dry dressing. On 8/20/2014 at 10:00 AM and 1:50 PM, the resident was observed in bed positioned on his back. At 1:50 PM, the resident told the surveyor he needed assistance with incontinence care. The Unit Manager entered the room, turned on the call light, and a certified nurse aide (CNA) came in to the room to assist. On 8/21/2014 at 10:30 AM during a dressing change observation, the sheet covering the resident had visible soiling with brown material to the edge and near the residents elbow. The licensed practical nurse (LPN) turned the resident to the left side. The coccyx pressure ulcer was observed without a dressing present. A large amount of drainage was present on the soaker pad under the resident, and a strong odor was present in the room. The base of the pressure ulcer was pink and moist, with the surrounding area red. On 8/21/2014 at 11:10 AM, the CNA#1 was observed in the resident's room providing care with the door was closed. At 11:15 AM on 8/21/2014, CNA #1 was interviewed and stated he came on duty at 6:30 AM. He stated the resident stayed in bed to eat breakfast and following breakfast, the resident refused care. The CNA stated he returned to do care at the time the resident's dressing was being done. He stated when he checked the resident for bowel incontinence at the beginning of the shift, he did not provide any care. CNA #1 stated he did not notice whether the resident's dressing was off at that time. The unit LPN was interviewed on 8/21/2014 at 11:57 AM and stated she was unaware the resident's dressing was off, prior to the dressing change. She stated the previous shift did not report any problems with the dressing. She said she would expect to be notified if the dressing fell off and would reapply it to protect the wound. The Unit Manager RN was interviewed on 8/25/2014 at 10:05 AM and stated the resident was alert and oriented, and able to call if he was incontinent of stool or if the dressing came off or loosened. She also stated it was important to keep the wound covered to prevent bacteria from entering the wound and causing infection. CNA #2, who worked the night shift on 8/20-8/21/2014, was interviewed on 8/25/2014 at 3:20 PM and stated she made rounds during the shift and did not see the dressing or notice it was off. CNA #2 did not recall any episode of incontinence of stool during the shift and did not change the resident. 10NYCRR 415.12(c)(1)(2)

Based on record review and interview conducted during the standard survey it was determined for 2 of 6 residents (Residents #3 and 19), reviewed for Foley catheters (urinary drainage tube), the facility did not ensure appropriate treatment and services were provided. Specifically Resident #3, did not have medical justification for the 2 month use of a Foley catheter; was not provided with the appropriate size catheter as ordered by the physician; and did not ensure proper infection control techniques were followed when the catheter tubing dragged on the floor. For Resident #19, the Foley catheter was not care planned and timely interventions were not rendered. This resulted in actual harm for Resident #3 and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #19. Findings include: 1) Resident #3 had [DIAGNOSES REDACTED]. The resident's care guide (care instructions), dated 10/20/2013 documented the resident required assistance of one to use the bathroom. The Minimum Data Set (MDS) assessment, dated 04/16/2014, documented the resident's cognition was moderately impaired, she was always continent of bowel and bladder, did not use a urinary catheter, and required limited assistance with toileting. The licensed practical nurse's (LPN) progress note, dated 5/30/2014, documented the resident was continent of bowel and bladder and ambulated to the bathroom ad lib with a walker. The resident's care guide updated 6/8/2014, documented the resident required assistance of one to use the bathroom, and did not document the use of a catheter. The updates on 6/8/2014 included contact isolation precautions and to discard urine from the drainage bag to the hopper inside the soiled utility room. The nursing progress note, dated 6/9/2014 at 1:15 AM, documented the resident was positive for Escherichia Coli (E-Coli, bacteria) in the urine, was put on contact isolation precautions, and instructed to use the bedside commode. The resident was found using the bathroom and reeducated to use the bedside commode. The registered nurse (RN#3) Manager's progress note, dated 6/10/2014 at 4:22 PM, documented the resident had E-Coli positive for Extended-Spectrum Beta-Lactamases (ESBL, highly resistant organisms) in the urine. The resident was on [MEDICATION NAME] treatment with [MEDICATION NAME], was asymptomatic, had intermittent bladder incontinence, and was non-compliant with contact isolation precautions. She documented she made the recommendation for contact precautions, and for the resident to have an indwelling Foley catheter temporarily while [MEDICATION NAME] treatment was ongoing and until ESBL in the urine was resolved. When the surveyor attempted to interview RN #3, she was unable for interview on 3 separate days (8/21, 8/22 and 8/25/14). Review of the electronic physician's orders [REDACTED]. The orders documented: -insert indwelling Foley catheter for infection precautions and incontinence, -contact isolation for positive ESBL in the urine, -[MEDICATION NAME] tablet 1 gram (g) (a urinary antiseptic drug) two times a day for [MEDICATION NAME] for UTI, and; -vitamin C tablet 500 mg two times a day for supplement. The nursing progress note, dated 6/10/2014 at 8:34 PM, documented the resident refused the Foley catheter. The nursing progress note, dated 6/11/2014 at 3:51 PM, documented the resident had an elevated temperature of 101.8 degrees F (Fahrenheit) associated with shivering, and continued to refuse the Foley catheter. The physician's orders [REDACTED]. The nursing progress note, dated 6/12/2014 at 5:14 PM, documented the resident had an indwelling Foley catheter for "incontinence" and contact isolation precautions. The physician's orders [REDACTED]. The comprehensive care plan (CCP), dated 6/12/2014, documented the resident had a UTI and was positive for E. Coli and ESBL in the urine. Interventions included contact precautions and disposing of urine using the soiled utility room hopper. On 6/16/2014, the CCP was updated to include educating the resident to report leaking of the Foley catheter. The CCP did not document interventions for the Foley catheter size or care. The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. The June 2014 MAR indicated [REDACTED]. The nurse practitioner's note, dated 6/26/2014, documented the resident attempted to pull her Foley out last evening and had some blood tinged urine due to "trauma." The nursing progress note, dated 6/26/2014 at 1:58 PM, documented the resident had her Foley out, urine was all over the floor, and the resident was refusing care. The June 2014 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The July MAR indicated [REDACTED]. The August 2014 MAR, documented the resident received it 5 times between 8/1 and 8/19/2014. The treatment administration record (TAR), dated July 2014, documented change Foley catheter, size 16 F every 8 weeks, and Foley catheter care every shift. The physician's orders [REDACTED]. The nursing progress note, dated 7/21/2014 at 9:59 PM, documented the resident's Foley catheter was found on the floor in the resident's room, the resident stated she did not know how it came out, and the resident refused to have another Foley catheter inserted. The nursing progress note, dated 7/21/2014 at 11:48 PM, documented a 22 F Foley catheter with a 30 cc (cubic centimeter) balloon was inserted. The nurse also documented she checked the records and could not find the size and used a 22 F with 30 cc balloon as the resident told her the "catheter fell out." The CCP, updated 7/24/2014, documented Foley catheter care interventions including changing the Foley every 8 weeks with a 16 F Foley and 5 to 10 ml sterile water in the balloon. The TAR, dated August 2014, documented change Foley catheter every 2 months, use 16F catheter size and instill with 5 to 10 milliliters (ml) of sterile water. On 8/21/2014 at 8:35 AM, the resident was observed in her wheelchair self-propelling through the hallway, the covered Foley bag was dragging on the floor and the tubing was directly on the floor. On 8/21/2014 at 9:30 AM, the resident was observed backing out of the elevator in her wheelchair. The urine filled catheter tubing was dragging on the floor and the resident's foot landed on the tubing as she used her feet to push herself out of the elevator. During a resident interview, on 8/21/2014 at 2 PM, the resident stated she did not like having a Foley catheter, she was not sure why she had it, she had a hard time getting around with it, and it looked dirty. On 8/22/2014 at 7:40 AM, the resident was observed in bed, the Foley tubing was resting on the floor and the drainage bag was not covered and hanging from the bed. On 8/25/2014 at 9:10 AM and 11:15 AM, the resident was observed in bed, the Foley drainage bag was not covered and resting on the floor. During an interview and care observation on 8/25/2014 at 11:20 AM, the CNA stated the reason the resident had a Foley catheter was for contact precautions. She stated the resident used to be able to go to the bathroom by herself, but then she got sick and became incontinent with ESBL in the urine. She stated the drainage bag and tubing should not be on the floor and she picked the bag up and hung it on the bed, she checked the resident's Foley catheter and stated the size read 22F/30cc. During an interview, on 8/25/2014 at 11:40 AM, RN Manager #4 (covering the unit for RN #3) stated the resident had a Foley catheter for infection control purposes to contain the urine. She did not know if the use of a Foley catheter was part of the facility's infection control policy. She stated the urine was rechecked frequently to determine if the infection was cleared and Foley was still needed. She stated a urine specimen was collected yesterday and they were awaiting results. RN #4 then looked through the medical record and stated this was the first specimen collected since the Foley catheter was initiated. She stated the physician's orders [REDACTED]. During an interview, on 8/25/2014 at 12:45 PM, the nurse practitioner (NP) stated the resident had a Foley catheter to contain the urine due to ESBL. She stated a size 16 F Foley was ordered and would expect to be notified if another size was used. During an interview, on 8/26/2014 at 9:05 AM, the resident's physician stated Foley catheters were not used for infection control purposes. He stated he thought the resident came from the hospital with the Foley and he was planning to discontinue it. He stated he did not know how long the Foley catheter had been in and would have expected it to be out by now. He stated if it was for infection control purposes, it should have been in only during the antibiotic treatment [MEDICATION NAME] 10 to 14 days. He stated if a different size Foley catheter was used, he expected to be notified within 24 hours. He also stated there was a "huge" difference between a 16 F and a 22 F and stated a 22 F was "too large." During a phone interview, on 8/26/2014 at 10:10 AM, RN #5 (responsible for inserting the 22F Foley catheter) stated she could not find an order for [REDACTED]. She stated an order was needed to change the catheter size, she did not obtain the order, and asked the day shift nurse to take care of it. During an interview, on 8/26/2014 at 12:30 PM, the Director of Nursing (DON) stated the resident had a Foley catheter to contain her urine for infection control purposes. She stated she did not want to expose anyone else to the resident's urine and did not have a private room available for the resident. She also stated it was common practice to use a Foley catheter for resident's with ESBL in the urine. She stated the policy was to decide on a case by case basis if a Foley catheter was needed for contact precautions. When the DON was asked by the surveyor to show where in the Contact Precautions policy the use of a Foley was indicated, she stated there was a different policy for ESBL and she would get it. She also stated she was aware a 22 F Foley catheter was used in place of a 16 F Foley and stated an order was needed and the physician should have been called. On 10/26/2014 at 1 PM, the DON brought a "fact sheet" to the surveyor for ESBL and both reviewed this sheet. There was no documentation on this "Fact Sheet for ESBLs" that Foley catheters were recommended. This sheet documented that the CDC (Center for Disease Control) recommended that long term care facilities use contact precautions on a case by case basis. 2) Resident #19 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A physician order [REDACTED]. The current undated certified nurse aide (CNA) care guide (care instructions), documented the resident required maximum assist with bed mobility and required a Hoyer lift for transfers. The care guide did not include the resident's indwelling Foley catheter and did not provide guidance to the CNA on how to care for the Foley catheter or when to report to the nurse. A nursing progress note dated 7/27/2014 at 3:30 PM, documented the resident's Foley was patent and draining dark yellow urine and fluids were encouraged. A nursing progress note dated 7/30/2014 at 3:19 PM, documented the resident's Foley was patent and draining dark brown colored urine and fluids were encouraged. The comprehensive care plan (CCP) dated 7/31/2014, did not document the resident had a Foley catheter and did not contain any guidance on how to care for the resident's indwelling Foley catheter. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired, was totally dependent on staff for most activities of daily living (ADLs) and the resident had an indwelling catheter. A registered nurse (RN) progress note on the following dates: 8/6, 8/9-8/15, 8/17, 8/19-8/24/2014 documented the resident was observed for GU ([MEDICAL CONDITION]) concerns and no concerns were observed. On 8/25/2014 at 0815 AM, the resident was observed with the Foley catheter on the side of the bed facing the wall. The Foley catheter drainage bag was sagging and had greater than 1000 cc (cubic centimeters) of urine in it that was dark brown in color. The resident was again observed at 9:30 AM, 10 AM, 10:40 AM, 11: 15 AM and again at 1:15 PM with the catheter bag sagging and almost full containing very dark brown color urine. During an interview with the resident's family member 8/25/2014 at 11:45 AM, he stated his father's urine has been that color for more than a couple of days and the resident was very sleepy today. During an interview with CNA #4 on 8/25/2014 at 12:10 PM she stated she would empty the Foley's drainage back at the end of her shift at 3 PM. She stated she had not told anyone about the color of the resident's urine, because sometimes his urine was a dark color like that and, other times, it was yellow. During an interview with the registered nurse (RN) #2 on 8/25/2014 at 1 PM she stated the resident ate and drank "ok" and his urine had always been a yellow color as far as she knew. She stated it was her responsibility or the responsibility of the Unit Manager to initiate a care plan for a resident with an indwelling Foley catheter. At 1:10 PM, RN #2 (with the surveyor) observed the resident's Foley catheter bag containing dark colored urine. RN #2 stated the resident's urine was, "cola colored" and not normal for him. She stated the CNA should have emptied the drainage bag by now and the CNA should have come to her or the licensed practical nurse (LPN) with the change in the resident's urine color. LPN #1 was interview on 8/25/2014 at 1:20 PM and stated she had not noticed the resident's urine being dark and the CNA should have notified her regarding the abnormal color. 10NYCRR 415.12(d)(2)

Based on record review and staff interview conducted during the abbreviated survey, Complaint # NY 355, it was determined for 1 of 4 residents reviewed for a change in condition (Resident #1), and 1 of 5 residents reviewed for advanced directives (Resident #1)the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, for Resident #1, the facility failed to : - appropriately assess and communicate a significant change of resident condition to the appropriate medical personnel; -carry out cardiopulmonary resuscitation (CPR) when the resident had an order and desire to be resuscitated; -operationalize protocols for code blue events in accordance with professional standards of quality; and - ensure adequate numbers of CPR trained staff were available for each shift. This resulted in actual harm that was Substandard Quality of Care and Immediate Jeopardy to the health and safety of Resident #1. The Immediate Jeopardy situations were removed on [DATE] and 11, 2012 prior to the abbreviated survey exit conference. Findings include: 1) FAILURE TO APPROPRIATELY ASSESS AND COMMUNICATE A SIGNIFICANT CHANGE IN RESIDENT CONDITION TO APPROPRIATE MEDICAL PERSONNEL: Resident #1 had [DIAGNOSES REDACTED]. The February 3, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. The comprehensive care plan (CCP), revised on February 14, 2012, documented the resident was a full code (wanted cardiopulmonary resuscitation (CPR) in the event the heart stopped) and the resident's medical condition was terminal. The nursing progress notes documented: - on [DATE] at 11:00 AM, licensed practical nurse (LPN) #4 documented the resident vomited mucous and bile, complained of not feeling well, had normal vital signs, and asked to go to the hospital. The registered nurse (RN) Supervisor, RN #2, offered the resident pain medications which she refused. The resident rang her call bell 27 times in 2 hours; - on [DATE] at 3:25 PM, LPN #5 documented the aides told her the resident refused to be cleaned up. Bile colored stains were seen on the bed sheets and clothing protectors, the resident's blood pressure was ,[DATE], and temperature was 100 F. The Supervisor (RN #3) was notified and the plan was to monitor and report any changes; - on [DATE] at 3:45 PM, RN #3 documented the resident refused all care and medications. Staff were encouraged to re-approach throughout the shift and the "(nurse practitioner) is aware;" - on [DATE] at 9:00 PM, RN #1 documented the resident had an earlier episode of vomiting and at that time was lying in bed covered with multiple blankets. The resident was alert/oriented and able to make her needs known. Her temperature was 100.1 and she was taking sips of ice water; - on [DATE] at 9:30 PM, LPN #2 documented the resident's blood pressure was ,[DATE], she spoke clearly to the nurse, and she denied pain/discomfort; - on [DATE] at 10:45 PM, RN #1 documented staff reported the resident vomited brown, "fecal smelling" emesis. Her temperature was 100.3 F, her abdomen was distended, and bowel sounds were positive. The nurse reminded staff to encourage sips of clear liquids; - on [DATE] at 2:00 AM, LPN #2 documented the resident's temperature was 100.7 F and she was sitting in her bed reading her mail; and - on [DATE] at 3:50 AM, RN #1 documented she received a call from the unit that the resident was non-responsive. RN #1 responded to the unit, the ambulance arrived and the resident was transferred to the hospital. Interviews conducted during the abbreviated survey revealed the following: - Certified nurse aide (CNA) #2 stated during interview on [DATE] at 12:00 PM, she began caring for the resident on [DATE] at 6:30 AM. At 8:30 or 9 AM, the resident rang her bell. She was "soaked with urine," had "garbled" speech, was out of breath, complained of pain in the stomach/back, and asked for medical attention. Her vital signs were normal. CNA #2 notified LPN #4 who called RN #2. RN #2 came to the unit and said there was nothing medically wrong with the resident at that time. - RN #2 stated in an interview on [DATE] at 4:05 PM, she was the Supervisor on [DATE] between 7 AM to 11 AM and she saw the resident at 9 AM. The resident complained of stomach pain, refused to be assessed, refused medications, and her vital signs were "fine." RN #2 was not told the resident had vomited at that time and received no further information from the unit prior to her shift ending at 11 AM. In a written statement dated [DATE], RN #3 documented she received report from RN #2 at 11:00 AM on [DATE]. She was told the resident was ill, had emesis and refused care. In a written statement dated [DATE], CNA #5 documented she started work at 9:30 AM on [DATE]. Sometime during the shift (time not specified), the resident started vomiting "yellow stuff." She told LPN #4 who told RN #3. During the shift, the resident rang her call bell repeatedly and asked for a doctor. Additional interviews conducted during the abbreviated survey revealed the following: - CNA #2 stated in an interview on [DATE] at 12:00 PM, sometime in the afternoon of [DATE], the resident started vomiting. At 3 PM, her blood pressure was ,[DATE] and her temperature was 100.1 F. The resident had not gotten out of bed all shift, which was unusual and she refused meals. Before supper, RN #3 came to the unit, stated the physician was aware of the resident's condition and there was not a reason to send her to the hospital. - LPN #5 stated in an interview on [DATE] at 5:25 PM, she took over care at 2:30 PM on [DATE]. She was told in report the resident was in bed all day with vomiting of bile and asked to go to the hospital. This was unusual behavior for the resident. At 3 PM she asked RN #3 to assess the resident. She told RN #3 the resident's blood pressure was ,[DATE], she was pale, refused care, and refused medications. RN #3 stated she would send a text message to the nurse practitioner (NP). LPN #5 did not hear the results of the text message. In a written statement dated [DATE], RN #3 documented on [DATE] at 3 PM, she was asked by LPN #5 to see the resident. The resident refused to be assessed and there was green bile on the sheets. She sent a text message to the NP with the resident's vital signs and the fact she was vomiting. She documented she was not looking for any new orders. On [DATE], the Assistant Director of Nursing (ADON) transcribed the text message sent by RN #3 to the NP on [DATE] at 3:45 PM. The message documented "(resident) on 3 North is refusing care and meds. She had small emesis of green bile she just c/o not feeling well" her daughter was here visiting and is aware; temp 99.5, BP ,[DATE] otherwise VS normal not really looking for an order just making you aware." There was no evidence the text message was received and/or read by the NP and no documented response written by the NP. Interviews conducted during the abbreviated survey revealed the following: - on [DATE] at 5:25 PM, LPN #5 stated at 4 PM on [DATE], the resident refused her offer of pain medications. At 6:30 PM, she turned over care to LPN #3. - LPN #3 stated in an interview on [DATE] at 11:55 AM, he was told during report at 6:30 PM on [DATE], the resident had vomited, her vitals signs were abnormal, and he "assumed" the physician was contacted. When he saw the resident at the start of the shift, there was brown emesis on the sheets. He saw her again around 7 PM. At 7 PM, she was lying in bed, there was an odor in the room as though she was incontinent, her voice was "raspy" and she said she was sick. He did not question her further and he gave her a drink. -CNA #2 stated in an interview on [DATE] at 12:00 PM, that at 6:30 PM on [DATE] she updated LPN #3 of the resident's status. LPN #3 stated he did not know the resident well and would call RN #1. RN #1 came to unit around 6:30 or 7:00 PM and CNA #2 did not know what RN #1 did. - LPN #3 stated in an interview on [DATE] at 11:55 AM, sometime after 7 PM, he was told the resident's blood pressure was high. It was checked again at 9:00 PM, and it was ,[DATE]. At 9:30 PM, he updated RN #1 and told her the resident was vomiting and not her "normal self." LPN #3 stated that RN #1 told him in front of 3 other staff members, that the resident was not going to the hospital because if they sent her back without admitting her, the facility would be responsible for the cost. LPN #3 did not know if RN #1 contacted a physician. At 10 PM, the resident vomited and the aides thought it was coffee ground emesis that smelled like stool. He was scheduled to work on another unit and before he left, he asked LPN #2 if he wanted him to stay and help with the resident. - CNA #2 stated in an interview on [DATE] at 12:00 PM, at 10:30 PM on [DATE], the resident had brown emesis on her face, neck, back, and on the bed and her coloring was "purple." She and CNA #3 cleaned the resident and LPN #2 came into the room. CNA #2 thought the emesis was coffee ground and LPN #2 did not agree with her. CNA #2 left duty between 10:35 PM and 10:40 PM. - On [DATE] at 9:45 AM, CNA #4 stated she was working on another unit and went to the resident's unit to get paperwork at 10:30 PM on [DATE]. CNAs #2 and 3 asked her to look at the resident. The resident was lying in bed, her coloring was "yellow/brown/blue," and her breathing was labored. There were specks of brown matter on the sheets that she thought was emesis. LPN #2 came into the room and said he did not think it was coffee ground emesis. The resident said her pain level was 9 out of 10 and CNA #4 checked her pulse oximetry which was 84%. CNA #4 said she asked LPN #2 to do something and to give the resident oxygen. LPN #2 checked the medical record and said there was no an oxygen ordered. CNA #4 left the unit and went back to her assigned unit and she thought LPN #2 called RN #1. At 2:20 AM, she checked on the resident as she left for her lunch break. The resident said she was not feeling well. - On [DATE] at 12:20 PM, LPN #2 stated in an interview, he received report from LPN #3 on [DATE] at 10:30 PM. He was told the resident was ill, vomiting, and her blood pressure was elevated. He was also told RN #1 stated she was not going to be sent to the hospital. He did not ask the reason for this. At 11:00 PM, the resident's temperature was 103 F and her blood pressure was ,[DATE]. He thought those numbers were "slightly high" for her and did not check any prior documentation to compare to her usual blood pressure or temperature. He checked the resident and did not think she was her usual self. Her color was "abnormal." He was aware the resident did not have an order for [REDACTED]. He stated that the resident never received oxygen. - On [DATE] at 9:00 AM, CNA #1 stated she came into work at 10:30 PM on [DATE] and was told the resident was ill and in bed. She stated this was "totally different" for the resident. The resident rang the bell during the shift and she thought the resident was more confused then usual. At that time, she told LPN #2. At 2 AM, the resident was in bed reading her mail and her temperature was 100.7. She went to lunch from 2:55 AM to 3:25 AM, and checked on the resident first when she returned. At that time, the resident was not responsive and she notified LPNs #1 and 2. - LPN #2 stated in an interview on [DATE] at 12:20 PM, at around 2:30 to 3:00 AM, CNA #1 reported the resident was "gone." - On [DATE] at 3:30 PM, LPN #1 stated she received report at 2:30 AM on [DATE]. She was told the resident had been ill, vomited and the aides thought it was coffee ground emesis. She was told LPN #2 did not think it was coffee ground emesis. She was told the resident had not gotten out of bed all day and did not go outside to smoke. She stated this was very unusual for the resident. She was told told RN #3 called the doctor and he did not want her sent out. She did not see the resident until CNA #1 came to her at 3:40 AM and said the resident had "passed." On [DATE] at 12:30 PM, the NP stated in an interview, he received a call about the resident on [DATE] around 3 AM. He stated he received no calls before then and did not receive a text message related to her condition. The MD called the surveyor on [DATE] at 5:20 PM and requested to discuss Resident #1. The MD stated the NP called him and updated him. The MD stated he agreed with the NP's decision not to come to the facility to assess the resident. The MD stated the NP was on call on a rotating basis for the facility, had never been to the facility, and was approximately 100 miles away when he was on call. In summary, for Resident #1, the facility failed to : - appropriately assess a resident who complained of [MEDICAL CONDITION] pain, experienced emesis, and had a decrease in pulse oximetry; - closely monitor a resident with a change in condition; - address the resident's repeated requests to be assessed by a medical provider and/or be evaluated at a hospital; and -appropriately communicate any change in the resident's condition to medical personnel. ------------------------------------------------------------------------------------------The facility implemented measures to remove the Immediate Jeopardy situation on [DATE], including: - in-service education for all licensed nursing staff on addressing resident changes in condition which incudes timely and appropriate assessment and communication of abnormal clinical/medical findings to the medical practitioner. ------------------------------------------------------------------------------------------ FAILURE TO APPROPRIATELY CARRY OUT CPR: 2) Resident #1 had [DIAGNOSES REDACTED]. The February 3, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact. The comprehensive care plan (CCP), revised on February 14, 2012, documented the resident was a full code (cardiopulmonary resuscitation, CPR, in the event the heart stopped). The plan included reviewing advanced directives with the resident every 3 months and informing all staff of the resident's advanced directive wishes. The resident's MOLST (Medical Orders for Life-Sustaining Treatment) reviewed by medical staff on [DATE] (originally signed by the resident on [DATE]) documented the resident had decision-making capacity and made the decision to receive CPR in the event her heart stopped. The [DATE] nursing progress note signed by licensed practical nurses (LPN) #1 and 2 documented at 3:40 AM, they were informed by certified nurse aide (CNA) #1 that the resident "had passed." LPNs #1 and 2 went to the resident's room, found the resident without a pulse, called the nursing Supervisor, and started CPR. CPR was stopped at the request of the daughter and with the "doctor's permission." The [DATE] EMS (emergency management services) report documented at 3:42 AM, EMS arrived and found the resident lying on her back. There was a crash cart in the room and CPR was not being done at that time. EMS documented when the facility called 911, they stated CPR was started. EMS documented the resident was warm, pink, did not have rigor, and was asystole. EMS started CPR and transported the resident to the hospital. The [DATE] nursing progress note written at 3:50 AM by the registered nurse (RN) Supervisor (RN #1), documented: - LPN #1 called her and said the resident expired; - the resident was a full code, a code was initiated, and 911 was called; - the facility attempted unsuccessfully to reach the resident's niece and were able to reach her daughter who requested CPR to be stopped; - the nurse practitioner (NP) provided an order to stop CPR; - when the paramedics arrived, they re-started CPR and transferred the resident to the hospital; and - the NP and the resident's daughter were each called a second time and informed. On [DATE] at 9:00 AM, RN #1 stated in an interview, she received a call at 3:50 AM from LPN #1 who stated the resident had died . When she arrived to the floor, there were no staff members in the resident's room. She checked the chart, determined the resident was a full code, told LPN #1 to call 911 and the family, and went to the room with LPN #2. LPN #2 started chest compressions and RN #1 performed ventilation with an ambu bag. RN #1 left the room after 3 rounds of CPR as the oxygen tank ran out. While she was out of the room, she was told the resident's daughter wanted to talk to an RN. She took the phone call while LPN #2 continued compressions. The resident's daughter wanted CPR stopped and the NP was called for the order. When the paramedics arrived, they asked if the resident had a health care proxy. The resident's MOLST was in the chart and no health care proxy. The paramedics re-started CPR and transported the resident out of the facility. RN #1 stated she told LPN's #1 and 2 they should have started CPR prior to her arriving to the unit as the resident was a full code. She stated LPN #1 took the verbal order from the NP to stop CPR and she was not able to find the verbal order written in the chart. On [DATE] at 9:00 AM, CNA #1 stated in an interview, when she checked on the resident at 3:25 AM on [DATE], the resident was not responsive. She left the room and told LPNs #1 and 2 who went to the room. CNA #1 did not go to the room with the LPNs. A code blue was not announced overheard. CNA #1 observed one LPN call the Nursing Supervisor, who arrived to the floor ,[DATE] minutes later. When RN #1 arrived to the floor, LPNs #1 and 2 were at the nurse's station and no staff members were in the room with the resident. RN #1 asked LPNs #1 and 2 what the resident's code status was and one of them said she was a full code. RN #1 told LPN #1 to call 911 and RN #1 and LPN #2 went to the resident's room. On [DATE] at 12:15 PM, LPN #2 stated in an interview, he went to the resident's room with LPN #1 when CNA #1 said the resident was not responsive. He stated LPN #2 checked the resident's radial pulse and did not detect one. Neither he nor LPN #1 checked for an apical pulse or blood pressure. He said the resident's bracelet documented she was a full code and he and LPN #1 left the room to verify her code status in the medical record and call RN #1. He stated a code blue was not announced overhead and CPR was not started before the Supervisor arrived to the unit. He stated he did not know if he was obligated to start CPR and was not sure at that time if his CPR certification expired. When RN #1 arrived on the unit, she directed him to do compressions. He does not remember if RN #1 asked him if he was CPR certified. He said he continued the compressions until RN #1 told him to stop. He thought CPR was stopped for about 3 minutes when the paramedics arrived and re-started CPR. On [DATE] at 12:40 PM, the NP stated in an interview, shortly after 3:00 AM, he received a call from someone who identified herself as the Supervisor. The person on the telephone told him the resident was cold, cyanotic, had no pulse, no respirations, and she believed the resident expired. He was told the staff immediately called a code and started CPR. He stated since starting CPR, the resident's family had been called and did not want any heroic measures. He stated he provided an order for [REDACTED]. On [DATE] at 3:30 PM, LPN #1 stated in an interview, she was informed by CNA #1 the resident was not responsive and went to the room with LPN #2. The resident was lying on her back with black emesis down the front of her and she was not able to feel a pulse. She did not check the resident's identification bracelet for code status and left the room to check the code status in the medical record. She called RN #1 who arrived to the floor within ,[DATE] minutes. RN #1 and LPN #2 went to the room to start CPR. LPN #1 stayed at the nurse's station and called 911 and the resident's niece. She could not reach the niece, so she called the daughter who was the second person listed on the resident's face sheet. There was a MOLST in the chart and the resident did not have a health care proxy. She stated RN #1 wanted to talk to the daughter so she gave her the phone. She heard RN #1 tell the resident's daughter the resident was deceased and asked if it was okay to stop CPR. After that call, LPN #1 called the NP, told him the resident was deceased , the family wanted CPR stopped, and he said it was okay to stop CPR. When the paramedics arrived, they re-started CPR and LPN #1 called the resident's daughter and NP a second time to update them. On [DATE] at 1:15 PM, RN #1 stated in a second interview, when she arrived to the unit, LPNs #1 and 2 were at the nurse's station desk and no one was in the resident's room. She asked them why CPR was not started and LPN #1 told her it was not started as the resident was "dead." RN #1 told LPN #1 to call 911 and she took LPN #2 to the resident's room to start CPR. When she got to the room, the resident had vomited. She cleaned out her mouth and did not suction her. She used an ambu bag and LPN #1 did compressions. She stated after the resident was transported out of the facility she was frustrated with the level of knowledge of the staff as CPR was not initiated prior to her coming to the unit. On [DATE] at 11:55 AM, LPN #3 stated in an interview, he left the resident's unit at 10:30 PM to go work on the other unit on the same floor. At around 4:30 AM, he saw staff on the resident's unit "running around" and RN #1 stated the resident was "gone." He went to the room and someone was doing CPR. He stated a code blue was never announced overhead and he asked LPN #1 the reason. LPN #1 told him it was because the resident was "too dead" to call a code blue and if they had revived her she would have been in a vegetative state. The facility's CPR policy (undated) documented if a resident did not have a DNR order, CPR would be initiated for cardiac/pulmonary arrest, resident found unresponsive or choking, and a resident with a loss of vital signs. The first staff responding was to announce "code blue." The first CPR certified staff responding was to begin the assessment and initiate CPR. The second staff responding was to bring the needed emergency equipment. All other support staff responding were to be directed by the nursing Supervisor. In summary, for Resident #1, the facility: - failed to carry out cardiopulmonary resuscitation (CPR) for a resident with an order and desire to be resuscitated; and - failed to operationalize protocols for code blue events in accordance with professional standards of quality as a code blue was not called when the resident required CPR. 3) FAILURE TO ENSURE ADEQUATE NUMBERS OF CPR TRAINED STAFF WERE AVAILABLE FOR EACH SHIFT: On [DATE] at 12:30 PM, the Human Resources Director stated in an interview, upon hire, if someone was not CPR certified she communicated that information with the Staff Educator so she could follow-up and assist staff in maintaining or obtaining certifications. The Assistant Director of Nursing (ADON) stated in an interview on [DATE] at 2:30 PM, when staff were hired, Human Resources obtained a copy of their CPR certification. She stated that information was passed on to the Staff Educator who was to schedule recertifications and assist staff in maintaining their certification. The Staffing Coordinator was also to be provided with a list and was to ensure there was at least 1 CPR certified staff scheduled every shift. The ADON stated the Staffing Coordinator was not aware of this requirement prior to the incident on [DATE] and had since been instructed. The Education/Counseling Disciplinary Report dated [DATE] completed by the ADON documented the Staffing Coordinator was coached on the need for ensuring CPR certified staff were scheduled to work on every shift. The report documented there were no CPR certified staff scheduled on the night shift on [DATE]. The form documented the Staffing Coordinator's job description was reviewed and discussed with the Staffing Coordinator. The job description of the Staffing Coordinator signed on [DATE] did not document the responsibility of ensuring CPR certified staff were present for all shifts. The facility provided a revised job description signed on [DATE] which documented the Staffing Coordinator was to "complete daily assignments according to available staffing. Ensuring each floor has a CPR trained and certified LPN." During an interview on [DATE] at 11:20 AM, the Staff Educator stated at the time an employee was hired, Human Resources obtained a copy of their CPR certifications and kept track of the certifications. She stated she did not know the process they followed. She stated she posted information near the time clocks to inform staff when CPR training were to be offered. In summary, the facility failed to ensure adequate numbers of CPR trained staff were available for each shift, the staff scheduler was familiar with the duties of her position and that staff were trained in the obligation to provide CPR to full code residents and the proper means to establish futility. ----------------------------------------------------------------------------------- The facility implemented measures to remove the Immediate Jeopardy situation on [DATE], including; implementation of a new system to ensure staff CPR certifications are kept current, CPR status is communicated to the staff scheduler and that adequate numbers of CPR certified staff are present during every shift. In addition, staff were trained in the duty to provide CPR for full code residents. 10 NYCRR 415.12

Based on record review and staff interview conducted during the abbreviated survey, Complaint #NY 355, it was determined for 1 of 4 residents reviewed for a change in condition (Resident #1), and 1 of 5 residents reviewed for advanced directives (Resident #1), the facility failed to ensure the Medical Director (MD) provided oversight to the medical care of all residents. Specifically, for Resident #1, the MD failed to respond to and appropriately assess a resident who had a change in condition and failed to provide medical orders to appropriately carry out CPR (cardiopulmonary resuscitation) on a resident who wished to be resuscitated. This resulted in actual harm that resulted in Immediate Jeopardy to the health and safety of Resident #1. Refer to F309. Findings include: On [DATE] at 1:44 PM, the nurse practitioner (NP) provided a verbal statement to the Assistant Director of Nursing (ADON) that was transcribed by the ADON. The statement documented the NP was contacted by a nurse who stated the resident was unresponsive, CPR was started, and the family wanted CPR stopped. The NP stated he did not know which nurse he spoke to and stated he gave an order to stop CPR. The NP stated he was called back about 20 minutes later and was told the paramedics wanted to re-start CPR. He told staff to comply with the paramedics. The MD called the surveyor on [DATE] at 5:20 PM and requested to discuss Resident #1. The MD stated the NP called him and discussed the details of this case after the DOH investigationg began. The MD stated he agreed with the NP's decision not to come to the facility to assess the resident. The MD stated the NP was on call on a rotating basis for the facility, had never been to the facility, and was approximately 100 miles away when he was on call. The MD stated he agreed with the NP's decision to order staff to stop CPR as staff told him the resident was deceased and the family no longer wanted CPR. The surveyor conducted a telephone interview with the NP on [DATE] at 12:30 PM. He stated he provided an order to stop CPR on Resident #1 after he spoke with the nurse. He stated the nurse he spoke to identified herself as the Supervisor and he believed from what he was told, CPR would be futile. He stated he was also told that a code was called, CPR was initiated, and the resident's health care proxy wanted CPR stopped. He stated he was called a second time and notified the paramedics wanted to resume CPR. He stated he did not agree but would not interfere with their decision. He stated at the time of the second call he did not know the resident was a full code. He stated he was told by the nurse that the family wanted no "heroic measures" for the resident. On [DATE] between 9:30 AM and 11:15 AM, the MD stated in an interview, he preferred new ways of communicating such as texting. He stated the plan for the facility to communicate with himself and/or the NP included sending text messages. In summary, the facility: - failed to ensure the MD, including the NP, responded appropriately to and assessed a change in Resident #1's condition; and - failed to provide medical orders to appropriately carry out CPR (cardiopulmonary resuscitation) on a resident who wished to be resuscitated. 10NYCRR 415.15 (a)(1)(2)(4)

Based on record review and staff interview conducted during the abbreviated survey, Complaint #NY 355, it was determined for 1 of 4 residents reviewed for a change in condition (Resident #1), and 1 of 5 residents reviewed for advanced directives (Resident #1), the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents related to code status and change in medical condition. Specifically, the QA Committee failed to ensure staff were trained on monitoring residents for changes in condition, failed to monitor the implementation of residents' code status wishes, and failed to ensure adequate numbers of CPR certified staff were available for all shifts. This resulted in actual harm that was Immediate Jeopardy to Resident #1's health and safety. Findings include: 1) Resident #1 experienced a significant change in condition on [DATE] including [MEDICAL CONDITION] pain at a level of 9 out of 10, emesis, and decreased pulse oximetry. The facility failed to closely monitor the resident's change in condition; failed to address the resident's repeated requests to be assessed by a medical provider and/or be evaluated at a hospital; and failed to appropriately communicate any change in the resident's condition to medical personnel. 2) Resident #1 was a full code and was found unresponsive on the morning of [DATE]. The facility failed to carry out cardiopulmonary resuscitation (CPR) when the resident had an order and a desire to be resuscitated, and failed to operationalize protocols for code blue events in accordance with professional standards of quality as a code blue was not called when the resident required CPR. 3) Resident #1 was a full code and was found unresponsive on the morning of [DATE]. The facility failed to have a system in place to ensure adequate numbers of CPR trained staff were available for each shift. The Administrator, who is a member of the QA Committee, was interviewed on [DATE] at 2:10 PM, and stated he became aware of the issues after reviewing the statements from the CNAs and nurses following the incident with Resident #1. He stated he realized that some staff members needed counseling, education, or discipline. He spoke with the Staff Educator and discussed providing education to staff on identifying and responding to changes in residents' conditions. He stated he planned to address his concerns in tomorrow's QA meeting. On [DATE] at 1:30 PM, the ADON (QA Coordinator) and DON were interviewed. They stated they called the Medical Director on the morning of [DATE] after the investigation was initiated. Through the investigation, they identified that staff did not respond appropriately to a change in the resident's condition and did not document appropriately. The DON and ADON began counseling staff and began training on the change in condition policy. The ADON stated she was unaware of issues with scheduling CPR certified staff on every shift and was not aware there was a breakdown in communication between the scheduler, Human Resources, and Staff Educator. In summary, the QA committee failed to: - ensure staff were trained on monitoring residents for changes in condition; - monitor the implementation of residents' code status wishes, and - ensure adequate systems were implimented to ensure staff were CPR certified and the facility was sufficiently staffed at all times with CPR certified staff. 10NYCRR 415.27

Based on observations, staff interviews, and record reviews conducted during the standard survey, it was determined for 2 of 5 residents (Residents #23 and 27) reviewed for tube feeding the facility did not ensure appropriate treatment and services were provided to prevent complications related to tube feeding. Specifically, Resident #23 developed a small bowel obstruction from her gastrostomy tube ([DEVICE], a tube inserted into the stomach) and required hospitalization with medical intervention as the facility: did not implement interventions to prevent migration of the [DEVICE] into the resident's abdomen; did not monitor the [DEVICE] consistently for migration into the resident's abdomen; did not have a physician's orders [REDACTED]. For Resident #27, the facility did not follow accepted standards of practice to determine [DEVICE] placement; and did not ensure staff were trained to replace [DEVICE]s. This resulted in actual harm that is not immediate jeopardy for Resident #23, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #27. Findings include: The facility's Gastrostomy Tube Protocol for Checking Placement and Patency of Tube and Assessment of Gastric Emptying, dated November 2005 documented to ensure proper positioning of the [DEVICE] and assess gastric emptying, staff are to instill 10 cc of air while listening (with a stethoscope) for the air to enter the stomach. 1) Resident #23 has [DIAGNOSES REDACTED]. The nursing notes dated September 9, 2011 documented the resident's [DEVICE] was retracted into her abdomen to "near the port" (the opening at the end of the tube). The note documented the supervisor was notified and instructed to pull the [DEVICE] back and fasten it to the resident's skin. The nursing note dated October 1, 2011 documented the resident's [DEVICE] continued to retract into her abdomen. The note recorded the [DEVICE] was pulled back, and taped to the resident's stomach. The physician orders [REDACTED].#22 French catheter (no balloon size specified). The orders documented the resident's [DEVICE] was last changed on July 1, 2011. The nursing note dated October 6, 2011 documented the resident's [DEVICE] had retracted into her abdomen, was pulled back and taped in place. The nursing note dated October 7, 2011 documented the resident's [DEVICE] continued to retract into her abdomen, was pulled back and taped in place. The comprehensive care plan (CCP) dated October 7, 2111 documented the resident was fed via a feeding tube. There was no documentation regarding the type of feeding tube or the catheter and balloon size. The CCP instructed to check the feeding tube for signs and symptoms of infection. There were no specific interventions recorded regarding monitoring for migration of the [DEVICE], what to do if the tube migrated into the resident's abdomen, or if the tube came out. The physician orders [REDACTED]. The orders directed to change the [DEVICE], every 60 days and as needed. The orders did not include the type and size of catheter or balloon to use when changing the resident's [DEVICE]. The Orders documented to check for placement of the [DEVICE] before administering feedings, medications and every shift. The treatment administration record (TAR) dated October 5 - 28, 2011, documented to change the resident's [DEVICE] as needed, using a #22 French catheter, the balloon size was not specified. The licensed practical nurse's (LPN #1) progress note dated October 28, 2011 at 2 PM documented the resident was found with the [DEVICE] out and the balloon intact. The note recorded LPN #1 replaced the [DEVICE] with no problems, and continued the resident's tube feeding. LPN #1's note did not include the type or size of catheter and balloon used to replace the [DEVICE], or if LPN #1 notified the supervisor or medical that the resident's tube had come out. Review of the 24 Hour Nursing Report and TAR for October 28, 2011 showed no documentation that the resident's [DEVICE] came out and was replaced. The TAR dated October 28 - November 8, 2011, documented to change the resident's [DEVICE], as needed, using a #22 French catheter, the balloon size was not specified. The Minimum Data Set assessment dated [DATE] documented the resident was totally dependant on staff for all activities of daily living, was in a persistent vegetative state, with no discernible consciousness, and was fed via a feeding tube. The nursing notes dated November 8, 2011 at 10:30 AM documented the resident had "greenish fluids" coming from her mouth and the [DEVICE] area. The note recorded the resident was sent to the hospital. The Hospital Discharge Summary dated November 10, 2011 documented the resident had a [MEDICATION NAME] study (a test to determine placement of the [DEVICE]) which showed the feeding tube was overinflated and was obstructing the jejunum (the middle portion of the small intestine). The summary recorded the physician deflated the [DEVICE] balloon from 30 milliliters (ml) to 15 ml and the resident's obstruction was relieved. The nurse practitioner's (NP) note dated November 10, 2011 documented the resident was sent to the hospital due to green drainage from her [DEVICE] and emesis. The note recorded the hospital physician found the resident's [DEVICE] balloon was overinflated. The NP documented that to their (the facility's) recollection they had not changed the resident's [DEVICE], so the over-inflation must have happened during a previous hospital admission. The NP recorded, upon the resident's return from the hospital (on November 10, 2011), she examined the resident and found her [DEVICE] was almost completely into her body. The note documented the resident was hypotensive, hyperventilating, and her abdomen was distended with no bowel sounds. The resident was sent back to the hospital where a computed tomography (CT) scan of her abdomen noted the [DEVICE] had moved and the balloon had caused an obstruction. The NP documented that orders were written to be sure the [DEVICE] was taped on the resident's stomach in a way that it could not retract into her abdomen. The CCP dated November 17, 2011 documented the resident was fed via a feeding tube. The CCP instructed to check the feeding tube for signs and symptoms of infection. There were no documented interventions to prevent the [DEVICE] from migrating into the resident's abdomen. There were no documented interventions regarding monitoring for migration of the tube, what to do if the tube migrated into the resident's abdomen, or if the tube came out. On December 6, 2011 at 9:32 AM, LPN #4 was observed administering the resident's tube feeding. The resident's [DEVICE] was not secured to her stomach. On December 8, 2011 at 9:40 AM LPN #4 was observed administering the resident's tube feeding. The resident's [DEVICE] was not secured to her stomach. During an interview on December 8, 2011 at 1:30 PM the physician stated she was not aware the resident's [DEVICE] had been replaced by LPN #1 on October 28, 2011. The physician stated the resident had a J-tube. She said he did not know why the resident had a J-tube instead of a [DEVICE] or when the J-tube was placed. A "Chart Review" dated December 8, 2011, was conducted by the physician, after speaking with the surveyor at 1:30 PM. The review documented there was a note in the resident's medical record dated October 28, 2011, that the resident's [DEVICE] came out with the balloon intact and an LPN replaced the [DEVICE]. The chart review recorded on November 8, 2011 the resident developed symptoms of a bowel obstruction and was sent to the hospital. When the resident arrived at the hospital her [DEVICE] had migrated down, via peristalsis, to the point where the tip was in the jejunum. It was then retracted so the [DEVICE] was in the stomach and x-ray verified that. The resident returned to the facility where the same thing happened, she had a small bowel obstruction because of migration of the [DEVICE]. The resident went back to the hospital for a short visit where the [DEVICE] was again retracted back up into the stomach. On December 8, 2011 at 4:40 PM, the registered nurse (RN) manager said someone here put too much air into the balloon of the resident's [DEVICE]. He stated they needed to keep the [DEVICE] taped in such a way that it would not advance and cause an obstruction. An observation of the resident, at the time of this interview, showed the [DEVICE] was not secured/taped in place. The RN manager said to the surveyor there should be a device on the [DEVICE] so it would not advance. During an interview, on December 9, 2011 at 10 AM, LPN #1 said on October 28, 2011 a certified nurses aid (CNA) told her the resident's [DEVICE] was out. LPN #1 said she thought she replaced the tube with a #18 French catheter with a 10 or 20 cc balloon, she was not sure. LPN #1 said she reviewed the physician's orders [REDACTED]. LPN #1 stated she may have used a #22 French catheter, she did not remember. She said she had no problem putting the tube in and thought she put 20 cc of water into the balloon. LPN #1 said she learned how to replace [DEVICE]s in school. She said she told the charge nurse she replaced the resident's [DEVICE]. There was no documented evidence provided by the facility that LPN #1 received training or demonstrated competence regarding care of or replacement of [DEVICE]s. The LPN charge nurse, interviewed on December 9, 2011 at 10:35 AM, said she did not have a vivid memory of the resident's [DEVICE] being replaced on October 28, 2011. She said if she had known she would have written a nursing note, and put it on the 24 hour report. During an interview with the Director of Nursing (DON) on December 9, 2011 at 10:40 AM she said the physician or NP should "absolutely" be notified before a [DEVICE] was reinserted. During an interview with the nurse practitioner (NP) on December 9, 2011 at 11:45 AM, she said she did not remember being notified when the resident's [DEVICE] came out. The NP stated she expected to be notified and would then instruct the nurse what size catheter to use for replacement. On December 9, 2011 at 12:34 PM, the nurse educator was interviewed and said she could find no evidence of training or competencies related to feeding tubes for RNs or LPNs currently employed by the facility. The resident was observed on December 9, 2011 at 4:15 PM. The [DEVICE] was not taped securely to the resident's stomach, the [DEVICE] was able to move freely under the tape. The LPN #5 stated at that time, she was working the evening shift and had not yet checked the resident. She stated the tube should be checked every shift to ensure it was secured and not able to move. In summary, the resident experienced harm when she developed a small bowel obstruction from her G- tube requiring hospitalization with medical intervention as the facility: - did not implement interventions to prevent migration of the [DEVICE] into the resident's abdomen; - did not monitor the [DEVICE] consistently for migration into the resident's abdomen; - did not have a physician's orders [REDACTED]. - did not ensure nurses were trained to replace feeding tubes. 2) Resident #27 had [DIAGNOSES REDACTED]. The physician note dated August 18, 2011 documented the resident was fed via a feeding tube. The licensed practical nurse's (LPN #2) progress note dated October 5, 2011 documented "[DEVICE] orders obtained to change prn" (as needed). The note recorded the [DEVICE] was removed and a new one was reinserted. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment, was fed via a feeding tube, was non-ambulatory and required total assistance with activities of daily living. The comprehensive care plan (CCP) dated November 22, 2011, documented the resident was at risk for gastro-intestinal (GI)discomfort secondary to GERD. The plan included to observe for signs and symptoms of distress. The CCP documented the resident received all nutrition via a feeding tube, resulting in risk for aspiration, and potential for altered nutrition and hydration. The plan included administering the tube feeding and water via the [DEVICE] and check for fecal retention and bowel sounds. The CCP did not document instructions to verify [DEVICE] placement by injecting 60 cc of air. The physician orders [REDACTED]. The orders included giving the resident 240 milliliters (ml) of water before and after each tube feeding. The Gastrostomy Tube Protocol for Checking Placement and Patency of Tube and Assessment of Gastric Emptying, dated November 2005 documented to ensure proper positioning of the [DEVICE] and assess gastric emptying, staff are to instill 10 cc of air while listening (with a stethoscope) for the air to enter the stomach. At 12 PM on December 7, 2011, a surveyor observed LPN #3, the medication nurse, as she flushed the resident's [DEVICE]. She checked for placement of the [DEVICE] injecting 60 cc of air from a syringe, and listening to the resident's stomach with a stethoscope. She checked for residual stomach contents by aspirating with the syringe. LPN #3 administered 240 cc of water through the [DEVICE]. The LPN stated in an interview, during the observation, the resident had a history of [REDACTED]. At 4:10 PM on December 7, 2011, in an interview, the registered nurse (RN) Director of Staff Development stated she was unable to provide documentation of training for nurses regarding caring for and replacing [DEVICE]s. The RN said she was employed at the facility since May 2011, and had not done any competencies with the nurses. During an interview with the Director of Nursing (DON) at 4:15 PM on December 7, 2011, she stated staff should inject 10 cc of air when checking [DEVICE] placement. She said if a greater quantity of air was injected, it would be documented in the physician's orders [REDACTED]. The DON stated 60 cc of air was "too much" to inject. In summary, the facility did not ensure the resident received appropriate treatment and services when they: - did not follow accepted standards of practice for determination of proper [DEVICE] placement prior to instillation of fluids; - did not refer to the CCP for instructions regarding determination of [DEVICE] placement; and - did not ensure staff were trained to care for and insert [DEVICE]s. 10NYCRR 415.12(g)(2)

Based on observation, record review, and staff interview conducted during the post survey revisit, it was determined for 1 of 4 residents reviewed for tube feedings (Resident #3), the facility did not ensure residents fed by tube feedings received the appropriate treatment and services to prevent tube feeding related complications. Specifically, when Resident #3 developed an area of impaired skin integrity as a complication from the feeding tube, the facility did not ensure the resident was evaluated timely by medical staff to determine if treatment was needed. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF DECEMBER 9, 2011. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The November 15, 2011 Minimum Data Set (MDS) assessment documented a BIMS (Brief Interview for Mental Status) was not completed and the resident required extensive assistance for activities of daily living. The comprehensive care plan (CCP), updated November 30, 2011, documented the resident was non-communicative and in a vegetative state. The January 26, 2012 physician's orders [REDACTED]. The February 5, 2012 the registered nurse (RN)'s progress note and a second note by a licensed practical nurse (LPN), both documented the resident had redness and excoriation around the tube feeding stoma. The area was cleansed and "house stock" moisture barrier cream was applied. The LPN's note documented the physician was notified. The resident's medical record contained no documentation related to the [DEVICE] stoma between February 6 and February 12, 2012. On February 13, 2012 at 10:15 AM, the surveyor interviewed the treatment LPN who stated she completed the resident's daily [DEVICE] dressing change earlier in the shift that day. On February 13, 2012 at 11:30 AM, the surveyor and the LPN observed the resident's [DEVICE] dressing. The surveyor observed blood on the dressing that was covering the resident's tube feeding stoma. The LPN told the surveyor that the area "bled" when she cleaned it that morning. The LPN lifted up the dressing and stated the resident had a [DIAGNOSES REDACTED] (small area of inflammation due to tissue injury). The surveyor observed a red, raised area at the stoma site. The LPN stated she thought the area was "fairly new", although she was not certain, as she did not care for the resident the previous week. She said they were waiting to see if medical staff were going to order a treatment. On February 13, 2012 at 11:47 AM, the Director of Nursing (DON) documented in a progress note that the resident had granulated tissue (connective tissue that grows in healing wounds) at the stoma site that bled when the LPN changed the dressing that day. The DON notified the nurse practitioner (NP) who ordered a barrier as needed to the irritated site and a consult with the wound care physician. The verbal NP's order, written by the DON on February 13, 2012 at 11:57 AM, documented the resident was to have a wound consult "this week" for a [DIAGNOSES REDACTED] to the [DEVICE] stoma and barrier cream was to be applied as needed for irritation. The surveyor interviewed the DON on February 13, 2012 at 3:30 PM. She stated the Treatment LPN notified her "that morning" that the resident's stoma bled when she cleansed it. The DON stated when the area was found on February 5, 2012, it was "documented as excoriation, but it was not excoriation, it was a [DIAGNOSES REDACTED]." She stated after the February 5, 2012 nursing notes were written, she would have expected the resident to be seen by medical staff, to have been referred to the wound care physician, and and for the concern to be documented on the 24 hour nursing report. The DON said she was "certain" this area was not documented on the 24 hour nursing report on February 5, 2012, as she reviewed all residents with tube feedings everyday since the standard survey. The DON was re-interviewed on February 13, 2012 at 4:29 PM. She stated the LPN who wrote the progress note on February 5, 2012 placed the resident on the list to be seen by the NP and did not call medical staff at that time. She said the NP did not see the resident the following day, as the NP was off for the next 3 days. The NP did not see the resident when she returned to the facility, and per the DON, the NP did not recall being asked to do so. The DON stated the resident could have been seen by another member of the medical team in the NP's absence and seen by the wound care physician on February 8, 2012. The DON stated [DIAGNOSES REDACTED]s were common complications of feeding tubes and the resident had a [DIAGNOSES REDACTED] in November of 2011 that needed to be cauterized (burning of the area to close off bleeding) by the wound care physician. In summary, when Resident #3 developed an area of impaired skin integrity as a complication from the feeding tube, the facility did not ensure the resident was evaluated timely by medical staff to determine if treatment was needed. 10NYCRR 415.12(g)(2)

Based on medical record review and staff interviews conducted during an abbreviated survey (complaint #NY 296), it was determined the facility did not provide 1 of 4 reviewed residents (Resident #5) the necessary care and services to attain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. Specifically, Resident #5 experienced harm, and required hospitalization when the facility did not ensure monitoring and interventions for sub therapeutic levels of an [MEDICAL CONDITION] medication as ordered; ensure adequate professional assessment for a change in condition related to [MEDICAL CONDITION] activity; and provide timely emergency care for the resident as his condition continued to deteriorate. This resulted in actual harm that is not immediate jeopardy. Findings include: 1) Resident #5 had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. Review of all physician and nursing progress notes revealed he had no documented [MEDICAL CONDITION] from the time of admission to January 29, 2011. The Medicare 30 day Minimum Data Set (MDS) assessment, dated September 2, 2010, documented the resident had moderate cognitive impairment. physician's orders [REDACTED]. The orders specified the resident was to have a [MEDICATION NAME] level (test to determine level of [MEDICATION NAME] in the blood stream) Q 2 weeks (every 2 weeks). A laboratory report, dated December 7, 2010, documented the resident's [MEDICATION NAME] level was sub therapeutic at 2.4 ug/ml (normal = 10-20 ug/ml). The Advanced Directive Policy Review Sheet, last reviewed December 8, 2010, documented the resident had full code status (would be resuscitated in the event of cardiopulmonary arrest). The CCP (comprehensive care plan), last updated December 8, 2010, documented the resident had a [MEDICAL CONDITION] disorder, with goals including therapeutic blood levels of [MEDICATION NAME] [MEDICATION]). Interventions included assessing the resident's neurological status; maintaining safety precautions during [MEDICAL CONDITION]; recording the time, length, and type of [MEDICAL CONDITION]; and monitoring the resident for therapeutic blood levels of [MEDICATION NAME]. physician's orders [REDACTED]. Physician orders, dated January 19, 2011, documented the resident as to continue to receive [MEDICATION NAME] 100 mg orally every 12 hours, and [MEDICATION NAME] levels were to be done every two weeks. A review of the resident's laboratory reports between December 7, 2010 and January 21, 2011, revealed no [MEDICATION NAME] levels were completed after December 7, 2010. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. A [MEDICATION NAME] level was not included in the orders. A progress note, written by the nurse practitioner (NP) at 11:30 AM on January 21, 2011, documented she assessed the resident for altered mental status, and recommended hospitalization for further evaluation. The hospital discharge summary, dated January 26, 2011, documented that on admission (January 21, 2011), the resident's [MEDICATION NAME] level was 3.1, and less than the therapeutic range, "so the patient was loaded with PO (oral) [MEDICATION NAME]." The corrected [MEDICATION NAME] level was 12 on January 26, 2011. Hospital discharge instructions included [MEDICATION NAME] 100 mg PO 3 times daily and [MEDICAL CONDITION] precautions. The discharge [DIAGNOSES REDACTED]. Readmission orders [REDACTED]. At 10:30 AM on January 29, 2011, the registered nurse (RN) supervisor wrote a progress note that documented she was called to see the resident because he was on the floor beside his bed. While enroute, the RN was stat (immediate response requested) called at 8:35 AM because the resident had [MEDICAL CONDITION] activity involving all extremities. The note documented the resident had [MEDICAL CONDITION] at 8:43 AM, 9:05 AM, and "continued with intermittent [MEDICAL CONDITION] activity." The NP was updated twice. There was a small amount of bleeding from the resident's mouth, prob(ably) related to the resident's "teeth clenching tongue." The note documented the NP would "provide further evaluation with staff to report if not eating lunch or unable to take meds (medications)." An addendum to the progress note, dated January 29, 2011 at 11:00 AM, documented the physician was notified "via the MD book." A licensed practical nurse (LPN#2) progress note, dated January 29, 2011, documented the resident was sent to hospital #1 at 12:40 PM that afternoon. A progress note written by LPN #1 on January 29, 2011 at 1:00 PM, documented the resident was observed on the floor at 8:25 AM, and had [MEDICAL CONDITION] activity from 8:30 AM to 8:45 AM. The note documented the resident "continued to seize off and on from 8:30 AM to noon." An acute visit note dictated by the Nurse Practitioner on January 29, 2011 documented the hospital [MEDICATION NAME] levels from January 26, 2011, morning [MEDICAL CONDITION] activity and that the plan was to send the resident to the hospital if he could not consume lunch. The Nurse Practitioner documented "there are no other interventions or medications available to treat this condition." The Resident Information Transfer Form, sent to hospital #1 from the facility on January 29, 2011, documented the resident was found seizing at 8:30 AM, continued with intermittent [MEDICAL CONDITION] at 9:40 AM, and was seizing at noon. Hospital #1's emergency department report, dated January 29, 2011, documented EMS (emergency medical service) staff reported the resident was having [MEDICAL CONDITION] activity when they arrived at the facility. The resident required intubation (insertion of a breathing tube) due to continuous [MEDICAL CONDITION], and was transferred to hospital #2 the same day. Review of hospital #2's medical records revealed the resident was admitted to the intensive care unit in [DIAGNOSES REDACTED] (continuous [MEDICAL CONDITION]) on January 29, 2011. The resident was found to have suffered a cerebral infarction (stroke) prior to his arrival. He underwent placement of a [MEDICAL CONDITION] (device inserted in the neck for breathing), and was discharged back to the facility as a hospice patient on February 23, 2011. A surveyor interviewed LPN #1 on February 9, 2011 at 11:00 AM. She stated she was alerted by staff on the morning of January 29, 2011 that the resident had a [MEDICAL CONDITION] and was on the floor. LPN #1 said she paged the RN nursing supervisor and told her the resident needed to be sent to the hospital. LPN #1 stated the supervisor called the NP, who told staff to place the resident in a chair and feed him. LPN #1 said certified nurse aide (CNA) staff refused to place the resident in a chair. She stated that she and LPN #2, who was present, both told the NP the resident should go to the hospital. "We just can't leave him on the floor." LPN #1 said the CNAs told her the NP said she would not send the resident to the hospital, because the last time he went to the hospital, he was "faking." LPN #1 stated she told the NP that the resident continued to have [MEDICAL CONDITION] at 11:30 AM. CNA #1 was interviewed on February 9, 2011 at 11:30 AM. She stated she heard the resident's bed alarm, and found him on the floor at 7:30 AM on January 29, 2011. She stated there were no side rails on the bed, and there was a mat on 1 side of his bed. The resident was on the side of the bed without the mat. CNA #1 stated when she checked on the resident about every 20 minutes during that morning until his transfer to the hospital, no staff were with him. She described the resident as having continuous [MEDICAL CONDITION]: the resident's jaw was clenched; he was drooling; blood was running from his mouth; his eyes were rolled back; and his head, shoulders, and back rose up from the floor as he seized. CNA #1 stated she cleaned him when he was incontinent of bowel and bladder during the [MEDICAL CONDITION]. CNA #1 stated she did not see the resident assessed by the NP or nursing supervisor that morning. At 1:00 PM on February 15, 2011, a surveyor interviewed the RN nursing supervisor about events preceding the resident's transfer to hospital #1 on January 29, 2011. The RN stated she was called at about 9:00 AM, and did not find the resident to be seizing at that time. Within a few minutes, the resident began to have a [MEDICAL CONDITION], which lasted 10 minutes. She assessed the resident's right side for injury and found none. She said she considered the event an unwitnessed fall. The RN said she telephoned the NP, who told her to apply oxygen to the resident, which would clear up his symptoms. The resident began to have multiple [MEDICAL CONDITION], which increased in severity. She stated she called the NP 3 times, and the NP was not at the facility during the first 2 calls. The RN stated that when the NP arrived and came to the resident's room, the NP stated nothing more would be done for the resident at the hospital. The RN said she could not recall if she witnessed the NP examine the resident. The plan was for the RN to remain with the resident, try to get him up for lunch, and if this was unsuccessful, more action would be taken. The RN stated she agreed with this plan, stayed with the resident for 10 minutes, and then left because the [MEDICAL CONDITION] stopped. The RN said she wrote a note in the MD communication book to tell the physician the resident had seized. On March 1, 2011 at 2:05 PM, a surveyor interviewed the RN Unit Manager about events preceding the resident's transfer to hospital #1 on January 29, 2011. He stated he was not scheduled to work on that day, and later wrote a summary nursing progress note dated January 29, 2011. After reviewing the January 29, 2011 nursing progress notes, the RN Unit Manager stated the resident should have been transferred to the hospital within 15 minutes from the time the [MEDICAL CONDITION] began. On March 3, 2011 at 11:40 AM, a surveyor interviewed the hospital #1 physician who treated the resident on January 29, 2011. The physician stated that immediately upon arrival, the resident was intubated due to a delayed gag reflex. The resident had repeated [MEDICAL CONDITION] even after he was medicated, and was then sent to hospital #2 for care by a neurologist. The physician stated the standard of care for [MEDICAL CONDITION] is immediate emergency room evaluation for a patient with a history of [MEDICAL CONDITION], but no recent [MEDICAL CONDITION]. A patient with recent [MEDICAL CONDITION] who does not return to baseline should be sent to the emergency room . LPN #2 was interviewed March 4, 2011 at 10:00 AM about events preceding the resident's transfer to hospital #1 on January 29, 2011. She stated she was assigned to the resident that day, and upon returning from a morning break, LPN #1 told her the resident was on the floor seizing. LPN #2 entered the resident's room, and saw the resident having a [MEDICAL CONDITION], in the presence of the RN nursing supervisor and several CNAs. LPN #2 stated the resident continued to have [MEDICAL CONDITION] throughout the morning, each [MEDICATION NAME] 5-10 minutes, with left arm and left leg tremors between [MEDICAL CONDITION]. She said the resident did not respond to stimuli; his eyes did not focus; and his jaw was clenched. LPN #2 stated that because of the continuing [MEDICAL CONDITION], the resident was unable to consume his morning dose of [MEDICATION NAME]. She stated that upon the NP's arrival on the unit, she and other staff told her the resident should be sent to the hospital. She said the NP told them that if the resident went to the hospital, the NP would be the one caring for him and in the emergency department, and hospital staff would only observe the resident. LPN #2 stated she did not see the RN supervisor or NP examine the resident. During an interview at 11:15 AM on March 4, 2011, CNA #2 stated that on the morning of January 29, 2011, she was notified by another CNA that the resident was on the floor seizing. She went to the resident's room and observed him making gurgling noises, his eyes rolled back, his jaw clenched, blood coming from his mouth, and his upper body arching up. CNA #2 stated that when the NP arrived on the unit, she wanted the resident placed in a wheelchair and fed. CNA #2 stated she and other staff refused to do this because the resident was at risk to fall and could not eat with his jaw clenched. She said she did not see the NP or RN nursing supervisor examine the resident. CNA #2 stated that at approximately 11:30 AM, she observed the nursing supervisor place a second call to the NP and report the resident was constantly seizing, with no interval between [MEDICAL CONDITION]. On March 9, 2011 at 9:00 AM, a surveyor interviewed the NP regarding events preceding the resident's transfer to hospital #1 on January 29, 2011. The NP stated she was contacted twice by the nursing supervisor, who told on the first call that the resident was having "intermittent [MEDICAL CONDITION] ([MEDICAL CONDITION] activity)." She stated her plan was to watch the resident and perhaps he would wake up. The NP stated that during the second call, the nursing supervisor said the resident had a [MEDICAL CONDITION] and was stable. The NP stated she later arrived and spent 30 minutes assessing the resident. She said she found the resident with his mouth partially open, and no other abnormalities, including loss of bowel or bladder control. She said she thought the resident might wake up and eat lunch, and if not, he could be sent to the hospital. She stated she called hospital #1's emergency department and spoke with a physician who agreed with her plan. She stated the prior subtherapeutic [MEDICATION NAME] level of 2.4 ug/ml was addressed and corrected during his hospitalization of January 21, 2011. In summary, the resident experienced harm, and required hospitalization for a serious illness when the facility did not: - ensure monitoring and interventions for sub therapeutic levels of an [MEDICAL CONDITION] medication as ordered; - ensure adequate professional assessment for a change in condition related to [MEDICAL CONDITION] activity; and - provide timely emergency care for the resident as his condition continued to deteriorate. 10 NYCRR 415.12

Based on observations, record reviews and interviews conducted during a partially extended abbreviated survey (#NY 391 and #NY 983), it was determined the facility did not ensure 4 (Residents #1, 3, 4, and 13) of 18 sampled residents reviewed for skin concerns received the appropriate care and services. Specifically, the facility failed to ensure nursing and medical staff, timely and consistently, assessed, monitored, and documented Residents #1 and 3's skin breakdown; and failed to ensure ordered treatments were consistently provided for Residents #1, 3 and 13. Additionally, the facility failed to ensure proper skin care was consistently provided after Resident #1's incontinence episodes; failed to evaluate the effectiveness of Residents #1 and 4's skin treatments and comprehensive care plans (CCPs), and failed to develop and/or revise alternative interventions. For Resident #13, the facility failed to ensure certified nurse aide (CNA) assignment/accountability records accurately reflected newly ordered skin treatment ([MEDICATION NAME]). This resulted in actual harm that is Substandard Quality of Care and not Immediate Jeopardy for 3 (Residents #1, 3, and 4) of the 4 residents cited, and no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy for Resident #13. Findings include: The facility's "Wound Rounds' policy, revised November 2010, specified the physician or nurse practitioner (NP) "assesses wound and makes recommendations for changes in treatment as necessary. Documents in progress notes any order changes and the rationale for change." 1) Resident #1's [DIAGNOSES REDACTED]. COCCYX/BUTTOCKS/PERI-AREA SKIN BREAKDOWN: The resident's CCP, reviewed by the interdisciplinary team on September 22, 2010 and December 15, 2010, documented the resident was at risk for skin breakdown. Interventions included: "keep skin clean and dry"; inspect the resident's skin with morning and bedtime care. Staff were to "identify, report, and intervene for any high risk area." The CCP specified the resident wore incontinence briefs "all the time"; staff were to "promote skin dryness by checking and changing "every 2-3 hours"; were to "assess the resident's peri-area and sacrum for signs of irritation, redness or skin breakdown; and document abnormalities and notify the physician". The physician signed and renewed orders, dated December 6, 2010, for the LPN was to perform weekly skin checks on shower day and to report to the RN any skin issues. Renewed skin treatments included medicated powder to the resident's peri-area 3 times a day after cleansing; [MEDICATION NAME] cream to the body as needed; and Skin Repair to lower legs in the morning and evening. The resident's toileting record, dated December 2010, documented staff were to "change brief every 2 hours." Review of this record revealed "blanks" on multiple days and multiple time frames (including December 2, 5, 7, 11, 12, 19, 23, and 27, 2010) regarding the resident's incontinence care. There was no documented evidence timely and proper incontinence care (including cleansing) was provided as planned. The TAR, dated December, 2010, that specified medicated powder was to be applied to the resident's peri-area 3 times a day after cleansing had the letters "d/c" (discontinue) documented. There were no documented staff initials on the TAR, or on the December 2010 CNA Assignment/Accountability Record that specified this care was provided. There was no documented order that this medicated powder was discontinued by medical staff in December 2010. Review of the December 2010 TAR revealed the resident's skin checks were not consistently performed as ordered, as there were no documented results in the resident's medical record of his skin checks by the LPNs on December 17, 20, and 27, 2010; and no skin checks were documented to be done as scheduled on December 10, 13, and 31, 2010. Review of the resident's CCP and Wound Record for December 2010 revealed no documented assessment of the resident's buttocks. The CNA Assignment/Accountability Record, dated "December 2010", did not specify the resident was to be turned and positioned. A nursing progress note, dated January 1, 2011 at 7 PM, specified the nurse was called to assess the resident's buttocks and found the resident with "denuded/macerated due to frequent incontinence", with a small area on the right buttock that was bleeding. A telephone order from the NP, dated January 1, 2011 at 7 PM documented for [MEDICATION NAME] cream (used as a barrier to protect skin from moisture and irritating substances) to be applied to the resident's buttocks, twice a day and as needed. Review of the resident's CCP and Wound Record for January 2011 revealed no documented assessment of the resident's buttocks. Review of the resident's January 2011 TAR revealed the twice a day [MEDICATION NAME] cream to the resident's buttocks was "blank" for the night shift application, specifying no cream was applied to the resident's buttocks on January 8, 9, 11, and 12, 2011. The Janaury 2011 TAR documented "d/c" (discontinue) next to the "medicated powder" treatment. There were no documented staff initials on the TAR that specified this medicated powder was provided as ordered. There was no documented order that this medicated powder was discontinued by medical staff in January 2011. Review of the resident's toileting record, dated January 2011, revealed staff were to "change brief every 2 hours." This record revealed "blanks" on multiple days and multiple time frames (including January 1, 4, 8, and 9, 2011) regarding the resident's incontinence care. There was no documented evidence timely and proper incontinence care (including cleansing) was provided as planned. Nursing notes, dated January 12, 2011 at 10:30 AM, documented the resident was sent to the emergency room at the hospital for an evaluation of lethargy, decreased appetite, severe pain in legs unrelieved by pain medications, and right lower leg reddened and warm to touch. Review of the resident's hospital wound care record, dated January 13, 2011, revealed the wound care nurse documented the resident had an excoriated peri-area and bilateral groin, with maceration around the wound, and scrotum [MEDICAL CONDITION] (also admitted with multiple pressure ulcers on his coccyx and feet). During the survey, the surveyor interviewed 6 CNAs (including those from all 3 shifts): CNA #4 on January 25, 2011 at 2:30 PM; CNA #2 on January 31, 2011 at 1:35 PM; CNAs #3 and #5 on January 31, 2011 at 1:35 PM and 3 PM, respectively); CNA #6 on February 6, 2011 at 7:30 AM and CNA #1 on February 10, 2011 at 2:40 PM regarding the status and care of the resident's skin. A summary of these CNA interviews revealed: - the resident had a rash on his scrotum and inner thighs "for the past year", and they were aware of an "open area" on the resident's buttocks when incontinence care was provided. The CNAs did not document this on their CNA records, "because the nurse applied cream to his sacrum and knew about the area." - CNAs did not always wash the resident's skin when his briefs were changed and were not aware the resident was to be turned and positioned every 2 hours; and one CNA "could only remember washing the resident's buttocks once" when providing care. Another CNA stated she thought he should have been turned and positioned, because of the sore on his backside. - CNAs did not complete the "CNA Skin Integrity Check" sheets for September 2010 through January 2011, because they were "rushed with care", and had the "impression the area on his coccyx had already been reported." -The nurse did not always check the resident's skin after his shower, "because the nurses were too busy." An LPN on the day shift was interviewed at 1:50 PM on January 25, 2011. He told the surveyor the resident's coccyx area was denuded on January 1, 2011, and it was documented on the 24-hour nursing report. The LPN said he heard directly from the CNAs that the resident was not being washed when he was incontinent and had his brief changed. The LPN stated that he reported this to the RN/UM. The DON was interviewed on January 21, 2011 at 11 AM and on January 25, 2011 at 9:15 AM. She was unable to discuss/provide information regarding the resident's status. On January 21, 2011 at 2:00 PM, the surveyor interviewed the Assistant Director of Nursing (ADON), who also functioned as the facility's wound care nurse (WCN). The ADON/WCN stated she was not aware of the resident's skin issues, other than his right heel pressure ulcer. The ADON/WCN said that a full body audit was not completed during the weekly wound care rounds. She said if a new area was found, the RN/UM was responsible for initiating a Wound Record for follow up by the wound care team. The ADON/WCN said the wound care team did not follow residents with rashes, excoriated or denuded skin areas, as those areas were followed by the NP. The ADON/WCN stated when she went to the hospital to observe the resident's wounds, it was the first time she knew of the resident's coccyx, peri-area and scrotum wounds. During the afternoon of January 31, 2011, the surveyor interviewed the RN/UM, who stated he heard from "someone" who reported the aides were not washing the resident's skin when he was soiled and changed. The RN/UM said he told the DON what he heard, but took no other action to follow up or assess the resident. The surveyor interviewed the NP on January 31, 2011 at 12:10 PM who stated she was notified on January 1, 2011 that the resident had denuded and macerated buttocks from frequent incontinence. She stated she gave a verbal order for [MEDICATION NAME] cream to the bilateral buttocks and said she did not assess the area. On February 10, 2011 at 2:00 PM, the surveyor interviewed the hospital's wound care nurse by telephone. She stated she observed the resident on January 13, 2011 the day after he was admitted to the hospital. She stated the resident's peri-area had a red circular diffuse rash, his scrotum was red and [MEDICAL CONDITION] and the entire area was excoriated, with blistering, wet, macerated skin. OTHER SITES OF RESIDENT'S #1's SKIN BREAKDOWN: The resident's Wound Record, signed and dated January 6, 2011 by the ADON/WCN, documented the resident had 2 "new" sites ("A" and "B") on his "right outer ankle" with ankle crossed out and "heel" written in. The wound was specified to be "pressure"; the word "pressure" was then crossed out and [MEDICAL CONDITION] was written. Site "A" was documented to be "Stage II" that measured "3.0 x 0.2" (unit of measure not specified), was wound bed was "unable to see bed, yellow with white. Site "B" was documented to be an unstageable "macerated blister"; measured "6.0 x 4.0"; had a pink bed; and had "moderate yellow drainage". The Wound Record documented dietary was notified "weekly" and rehabilition therapy was notified "as needed." The resident's CCP, updated January 6, 2011, documented the resident developed a "right outer heel secondary to [MEDICAL CONDITIONS]." No corresponding treatment was documented in the plan of care. Nursing notes, dated January 8, 2011 at 10:55 PM, documented the resident complained of "right foot hurting". [MEDICATION NAME] (narcotic pain medication) was administered. The ADON/WCN was interviewed on January 21, 2011 at 2 PM. She stated she completed documentation in the resident's medical record (including the Wound Record and progress notes) and dated them as "January 6, 2011" and "January 13, 2011". She stated she completed both the January 6 and January 13, 2011 documentation, after she returned from seeing the resident in the hospital on January 13, 2011. On January 10, 2011, a 7 AM - 3 PM nursing note documented a physical therapy (PT) screen was requested, as the resident's right ankle had "increased pain; requested NP to evaluate." At 10 PM, a nursing note documented the resident "complained of right heel pain"; [MEDICATION NAME] was given. On January 11, 2011 at 9:10 PM, the NP gave a telephone order for staff to "wash area on right outer aspect of heel with normal saline, pat dry, apply [MEDICATION NAME] ointment to wound, cover with [MEDICATION NAME] and apply padded dressing and re-evaluate in the morning." A nursing progress note dated January 11, 2011 at 930 PM, documented the supervisor was made aware of the resident's right heel with "open type blisters" that measured 6 centimeters (cm) x 6 cm. On January 11, 2011 at 9:30 PM, an RN note documented she evaluated the resident's heel and specified the skin was sloughing off around the heel wound and was whitish in color. The resident "also noted to have fluid filled blisters on inner aspect of right shin." review of the resident's medical record revealed [REDACTED]. Nursing notes, dated January 12, 2011 at 5 AM, documented the resident's right lower leg was warm to touch and very red with blisters up and down on shin; no changes were noted for the resident's "open area to heel, although strong odor noted." At 10:30 AM on January 12, 2011, nursing notes documented the resident's had a 99.2 degree temperature and his attending physician was "in to assess the resident due to increased lethargy, decreased appetite, and complaints of severe pain from legs not relieved with pain medication." There was no progress note documented by the physician in the resident's medical record that specified a physician's assessment of the resident's skin integrity. On January 12, 2011 at 10:15 AM, an order documented the resident was to be sent to the emergency room to be evaluated for "fever, [MEDICAL CONDITION] of the lower extremity and lethargy." The hospital's wound care record, dated January 13, 2011, documented the resident's: - left anterior lower leg was red, inflamed, scaly, with an irregular border, measured 20 cm x 20 cm; - left medial leg, with loosely adhered callous; periwound [DIAGNOSES REDACTED]; measured 5 cm x 5 cm, with tenderness; - right anterior lower leg was red, inflamed, scaly, with irregular border; measured 20 cm x 18 cm; - right mid-shin lower leg, with brown scabbed area; measured 2 cm x 0.5 cm. There was no documentation in the resident's facility medical records (including CCP, progress notes or Wound Records) regarding the status of his left leg prior to hospitalization . The CCP, updated on January 13, 2011 (while resident was hospitalized ), documented a "late entry" for the wound rounds completed on January 6, 2011. The note documented "area worse on heel and now covers back of heel as well. NP updated." On January 21, 2011 at 2:00 PM, the surveyor interviewed the ADON/WCN who stated she was following the status of the resident's right heel pressure area, and was unaware of his other skin issues. She stated she found out about the resident's skin problems when she went to the hospital to observe his wounds. She said after her hospital visit on January 14, 2011, she started a Wound Record and dated it January 6, 2011, and wrote a nursing note and dated it January 13, 2011 regarding the resident's skin issues. On January 31, 2011 at 12:10 PM, the NP was interviewed. She stated the resident had stasis ulcers on his lower legs and the physician sent him to the hospital for possible [MEDICAL CONDITION]. On February 10, 2011 at 2:00 PM, the surveyor interviewed the hospital's wound care nurse by telephone. She stated she observed the resident on January 13, 2011 the day after he was admitted to the hospital. She stated both of the resident's lower legs were inflamed and painful. In summary, Resident #1 experienced harm, as the facility: - failed to ensure staff properly cleansed the resident after each episode of incontinence; - failed to ensure all the resident's skin treatments were consistently provided as ordered; - failed to ensure the resident's painful lower extremities and excoriated peri-area and groin were assessed, received appropriate treatment, and had documented monitoring in a timely manner; - failed to ensure the resident's CCP and wound treatment were evaluated for their effectiveness; - failed to ensure medical staff were notified timely of all changes in the resident's skin integrity. 2) Resident #3 was admitted from the hospital on January 20, 2011 with the hospital discharge summary of that date specifying his [DIAGNOSES REDACTED]. The resident's admission physician orders, dated January 20, 2011, included the medications [MEDICATION NAME] (diuretic) 40 mg, twice daily, and [MEDICATION NAME] (a blood thinner). Nursing notes, dated January 20, 2011 at 3:30 PM, documented the resident was alert and oriented, and ambulating with supervision and a cane. The note specified the resident had a "wound area on right foot; see assessment form." On January 20, 2011, the registered nurse (RN) completed the Nursing Admission Assessment form and documented the resident had a "diabetic ulcer on right foot"; specified "none" for preventative/protective foot care; and that the resident had 2 + [MEDICAL CONDITION] of the lower extremities. There were no documented descriptions of the resident's right foot wound (for example: no size, color, drainage). The Admission History and Physical, dated January 21, 2011 and signed by the physician, documented the resident had "bilateral chronic [MEDICAL CONDITION] with ulcerations of bilateral feet". The physician documented that at that time, the resident had dressings to open areas on both his "lateral legs. There are skin changes consistent with chronic [MEDICAL CONDITION]." The physician's documented plan included: "wound care as ordered by Wound Care Team at" the facility. There was no documentation the physician had staff remove the dressing on the resident's legs to conduct a visual assessment. A Wound Record, dated January 21, 2011, documented the resident had "multiple" stasis ulcers on both lower extremities, with "excoriated, purple, sporadic, open areas." No measurements were documented. The treatment was to "moisturize". On January 22, 2011 at 7:20 AM, the LPN documented the resident returned from the hospital at 11 PM (the previous evening) and specified LPN the resident's "bilateral lower shin and ankles wrapped; no other skin issues noted." A verbal order from the nurse practitioner (NP), dated January 23, 2011 at 10:45 AM, and signed on January 24, 2011, documented the resident was to have "Ace (elastic) wraps to bilateral lower extremities, on 12 hours and off 12 hours." On January 25, 2011, the Wound Record documented the resident's multiple open areas on his bilateral lower extremities as "all areas intact." The Treatment Administration Record (TAR) for January 2011, documented Ace wraps were to be applied to the resident's bilateral lower extremities; on 12 hours (scheduled "on" at 6 AM); off 12 hours (scheduled "off" at 6 PM). Review of the TAR, dated January 23, 2011 through February 7, 2011, revealed "blanks" on January 27, 28, February 2, 5, and 6, 2011 for the times they were scheduled to be removed. There were "blanks" on the resident's TARs on January 30, February 6, and February 8, 2011 for the times the Ace wrapos were to be applied. The resident's comprehensive care plan (CCP), initiated January 25, 2011, and updated February 4, 2011 after the interdisciplinary team meeting, did not document the status of the resident's lower extremities and did not document the ordered interventions (Ace wraps). When the surveyor interviewed the unit LPN on February 7, 2011 at 1:50 PM regarding the resident's dressings to his lower extremities, he stated he completed the resident's wound treatment on January 21, 2011. The LPN stated the resident's legs were swollen and purple in color, with dry skin dry, and some scabbed areas. He stated there was a [MEDICATION NAME] dressing on the bottom of the resident's right foot. The LPN stated the facility did not use [MEDICATION NAME]. He stated this was the dressing from the hospital (with a green border and green writing on it.) The LPN said the [MEDICATION NAME] on the right foot covered a white, sloughy area; and the wound bed was not visible. The LPN stated he completed the ordered treatment and rewrapped the legs with the Ace bandages. The LPN said that shortly after he completed the resident's treatment, he was transferred to the hospital for evaluation of his renal condition. The surveyor observed the resident in his room at 1:10 PM on February 7, 2011, with the unit LPN. There were no Ace wraps present on the resident's lower extremities. Both lower extremities were swollen, dark purple in color, with black skin scales on each leg. Review of the TAR for February 7, 2011 at that time, revealed nursing staff documented on the TAR that these wraps were applied to the resident. On February 7, 2011 at 1:35 PM, the surveyor interviewed the NP. She stated she had not been notified by staff of any change in the [MEDICAL CONDITION] in the resident's lower legs. She stated that she saw the resident on February 5, 2011 and noted that staff had not been applying A&D ointment and Ace wraps to the resident's lower legs as ordered. She stated that what she just saw is not what she had heard in the morning report. When the surveyor interviewed the resident's attending physician on February 8, 2011 at 11:05 AM and asked her about visualizing the resident's legs and other wounds, the physician stated no staff were present when she assessed the resident. She stated the resident wore his pants and shoes at that time, and she did not have them removed to evaluate the resident's skin. She said the resident had wraps on his legs and she could see "discoloration above and below the wraps". The attending physician stated she did not look for any open areas" on the resident during his history and physical and had not seen the resident since that time. The attending physician, a surveyor, and a unit LPN observed the resident on February 8, 2011 at 11:25 AM. The resident had Ace wraps applied to his lower extremities. The physician told the surveyor she would dictate a progress note reflective of this visit. The physician's progress note, dated February 8, 2011, documented she performed a "wound care evaluation of (the resident's) feet only. I was asked to evaluate bilateral legs and feet for review of open areas." The physician documented it did "not appear to be a diabetic ulcer;" pulses were present; and the resident had "good sensation of his feet." His legs had [MEDICAL CONDITION]; were wrapped with Ace wraps; and were "unable to be visualized" that day. The physician's recommendation was to keep the resident's legs elevated during the day to assist with dependent [MEDICAL CONDITION]. The CCP, updated on February 8, 2011, documented Ace wraps to bilateral legs per physician's orders [REDACTED]. The resident was treated for [REDACTED]. During the surveyor's interview on February 11, 2011 at 12:20 PM, the RN/UM who completed the resident's Admission Assessment form and Wound Record, dated Janaury 20, 2011 stated she was busy with 5 admissions on January 20, 2011 and did not conduct a skin assessment for the resident. She stated she completed the documentation on January 21, 2011 but dated it January 20, 2011. She stated had not seen the resident's skin integrity before or during the time she completed his assessment paperwork. She stated she used all the description of the resident from reviewing the hospital notes and from discussing the residnet's skin with an LPN that did a treatment on January 21, 2011. In summary, the resident experienced harm, as the facility: - failed to ensure nursing and medical staff correctly identified, assessed and monitored the resident's lower extremities timely, as their condition deteriorated and became infected. - failed to ensure Ace wraps were consistently applied to the resident's lower extremities. 3) Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated September 15, 2010, documented the resident's cognitive skills for decision making as moderately impaired, and the resident required cues and supervision for most activities of daily living. The MDS documented the resident required extensive assistance of 2 persons for toilet use, had an indwelling urinary catheter, and was incontinent of his bowels most of the time. Review of the resident's treatment administration record (TAR) dated December 2010 and January 2011 documented to apply [MEDICATION NAME] ointment (zinc oxide and menthol) to "affected" (area not specified) area twice a day, as needed. The TAR documented the [MEDICATION NAME] was administered 53 (out of 62 opportunity) times for December 2010 and 16 times in January 2011. The registered nurse (RN) supervisor's progress note, dated January 8, 2011, documented staff reported the resident's right buttock had an open area that measured 2 centimeters (cm) x 0.5 cm, with excoriation; had open areas above the right buttock, and had excoriation on the left buttock. The Wound Record, dated January 2011, documented a Stage II ulcer on the resident's right buttock, measuring 2 cm x 0.5 cm. The wound was red, moist, and excoriated. The date of origin was documented as January 9, 2011 with [MEDICATION NAME] ointment. A nurse practitioner (NP) telephone order, dated January 8, 2011, discontinued the [MEDICATION NAME] "as needed" order and ordered it to be applied to the buttocks twice daily routinely and as needed after incontinence, for one week, then discontinue and re-evaluate. The January 2011 TAR for January 9, 2011 through January 16, 2011, documented [MEDICATION NAME] ointment was applied to the residnet's buttocks 12 of the 16 opportunities. A physician progress notes [REDACTED]. There was no documentation the physician assessed the area at that time. There was no documentation the NP or physician evaluated the resident's [MEDICATION NAME] treatment as planned. The January 2011 TAR documented the resident did not receive this treatment from January 17 to January 26, 2011. The physician's "Routine Status Evaluation", dated January 26, 2011, documented the physician did not document and assessment of the resident's skin at that time. A licensed practical nurse (LPN) progress note, dated January 26, 2011 at 11:35 PM, documented a skin check was completed while the resident was showered. The resident's left and right buttocks had a "2 x 2" (no unit of measurement) open area. The supervisor was notified. A telephone order from the NP, dated January 27, 2011 at 9:15 AM, ordered [MEDICATION NAME] ointment was to be applied to the resident's buttocks and excoriated areas twice daily and as needed. The ADON)/WCN's progress note, dated January 27, 2011 at 2:00 PM, documented the resident's reccurring excoriation on buttocks and coccyx were assessed by the NP, with a new treatment ordered. There was no documentastion by the NP of her assessment. A Wound Record entry by the ADON and dated January 27, 2011, documented the resident's buttocks and coccyx were excoriated; appeared to have old purple areas, with a new red area. The resident's January 2011 TAR documented [MEDICATION NAME] ointment was administered 7 of the 10 opportunities from January 27, 2011 to January 31, 2011. The resident's TAR for February 1, 2011 to February 8, 2011, documented [MEDICATION NAME] was applied 13 of the 14 opportunities. An LPN progress note, dated February 2, 2011 at 10:15 PM, documented the resident's scrotum, inner thigh, and buttocks were excoriated and treatment was rendered. An NP order, dated February 3, 2011 at 5:05 PM, documented staff were to apply A&D ointment to the resident's buttocks daily and as needed after cleansing. The Wound Record, by the ADON/WCN and dated February 3, 2011, documented the resident's skin was red and dry, with no open areas. The NP was "to evaluate". The treatment was "change to A & D," and the outcome was improved. There was no documentation from the NP that she evaluated the resident's skin as planned. The NP was interviewed on February 15, 2011 at 3:30 PM, regarding the [MEDICATION NAME] order that was discontinued from January 16 through January 27, 2011. She stated she did not know if the excoriated area on the resident's buttocks improved or worsened during that time period, and did not know what treatment was provided. When the NP was interviewed on February 15, 2011 at 3:30 PM, she stated she observed the resident's buttocks in "early January," and on January 27, 2011, and on February 8, 2011, and the redness was the same during all observations. There was no rationale provided for the lack of documentation. On February 8, 2011 at 1:50 PM, the surveyor, the NP and the RN/UM observed the resident's skin, while certified nurse aide (CNA #1) removed his disposable briefs. A small blood stains were visible on the back, inside area of the briefs. The CNA stated she did not know if the blood was "new". The RN/UM measured the reddened area (entire buttocks) to be 20 cm x 17 cm, with 2 open areas on the left buttock measuring 1 mm (millimeter) x 1 mm. The NP stated the area was "denuded," and she would call the 2 small open areas Stage II. The NP stated she would continue using [MEDICATION NAME] ointment as a treatment for [REDACTED]." The RN/UM stated, "He's been like that for 10 months or so, it gets worse, it gets better, there's some open areas and then they get better." An NP order, dated February 8, 2011 at 11:30 AM, discontinued the A&D ointment. A NP progress note, dated February 8, 2011 at 2:30 PM, documented the resident's buttocks were examined, there were chronic reddened areas on both buttocks with 2 Stage II areas bilaterally (on both sides), and the treatment would be changed to [MEDICATION NAME] cream. The Wound Record, dated February 8, 2011 by the RN/UM, documented the resident's buttocks had a denuded area which measured 20 cm x 17 cm, with "2 pinpoint (1 mm) open areas." The skin was dark pink, the treatment was [MEDICATION NAME] twice a day, and the outcome was described as "unchanged." The resident's TAR dated February 8 and February 9, 2011, documented [MEDICATION NAME] ointment was applied to the resident's buttocks area once of the 4 opportunities. On February 9, 2011 at 10:05 AM, the resident's physician was interviewed and stated she was not familiar with the resident's skin issues. She reviewed the Wound Care book and progress notes and stated, "Well, it's not working if it hasn't cleared up. I'll have to look at him." The physician stated, "(the NP) ordered the skin treatment, I didn't. I haven't seen his bottom in months." On February 9, 2011 at 10:08 AM, the resident's physician was observed as she examined the resident's buttocks in his room. She stated the current treatment was not effective, and she would change it. CNA #1 and CNA# 3 were present, and both stated the resident had been on their unit for 3 months and the redness on his buttocks, "gets a little better, gets a little worse, but it's always real red. We've been using the [MEDICATION NAME] all along." On February 9, 2011 at 10:15 AM, the NP was interviewed regarding the treatment for [REDACTED]. She stated, "It's not acute, it's chronic, so I would continue to use the same thing. I've had good results on patients with [MEDICATION NAME]. We have other residents who just have chronic redness on their butts." A physician's orders [REDACTED]. A physician's orders [REDACTED]. On February 14, 2011 at 3:40 PM, during an observation of the resident's buttocks, the LPN stated, "It's much better, so much less red." CNA #4 stated, "I was caring for him 3 weeks ago. I can't believe how much less red and excoriated it is." Th

Based on observations, staff and resident interviews and record reviews conducted during an partially extended abbreviated survey (#NY 391 and #NY 983), it was determined the facility failed to ensure pressure ulcers did not develop, and failed to provide the treatment and services to promote healing for 7 (Residents #1, 3, 10, 14, 15, 16, and 18) of 12 residents reviewed for pressure ulcers. Specifically, the facility failed to consistently implement the turning and positioning schedule for Residents #1 and 14; failed to accurately assess, implement preventative measures, and consistently provide pressure ulcer treatment for [REDACTED]. Additionally, the facility failed to ensure 2 of Resident #14's pressure ulcers were properly cleansed to prevent infection. The facility failed to provide Resident #15 with a recommended alternating air mattress, with documented rationale; delayed treatment of [REDACTED].#15 and #16's certified nurse aide (CNA) Assignment/ Accountability Record regarding the change in their skin treatment. For Resident #18, physical therapy did not develop their plan of care that addressed the deep tissue injury on his heel. This resulted in actual harm for Residents #1, 3, 10, 14 and 15 that is Substandard Quality of Care and not Immediate Jeopardy; and in no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #16 and 18. Findings include: The facility's "Pressure Ulcer Prevention" Policy, revised November 2010, documented: - Certified nurse aides (CNAs) complete a CNA Daily Skin Integrity form" and "inspects the resident's feet and toes and report any abnormalities." - Nurse Manager assesses skin and implements prevention protocols and develops comprehensive care plan (CCP) to address risk factors; updates CNA accountability record. - Assesses all new wounds to ensure an appropriate plan of care is developed. 1) Resident #14's [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident was moderately impaired cognitively needed extensive assistance of 2 for bed mobility, transferring, and personal hygiene. The resident used a wheelchair, was incontinent, and was on a turning and positioning program. The Braden Scale for Predicting Pressure Sore Risk dated December 6, 2010 documented the resident was at high risk. The CCP, dated December 6, 2010, documented the resident had impaired skin, a history of pressure ulcers, and was at risk for the development of pressure ulcers. The CCP specified the resident was to be turned and positioned every 2 hours and as needed. An "undated" CNA Assignment/Accountability Record documented the resident was to turn and position every 2 hours, the entry was crossed out and changed to every hour (this change was undated). The Turning and Positioning Program Form dated December 2010, documented the resident was to be turned and positioned every two hours. The signature sheet for the turning and positioning schedule from December 23 through December 31, 2010 was signed for 3 of 27 shifts. The Wound Record documented the resident developed a pressure ulcer on his right ischium (buttock)on December 28, 2010, that measured 3 centimeters (cm) x 4 cm, was described as a Stage I, dark red, and blanchable greater than 3 seconds. December 31, 2010 the pressure ulcer was unstageable, 1.5 cm x 1 cm with the center as a deep tissue injury 0.8 cm x 0.8 cm, "bed has white center, surrounding area Stage I", improved in size "worse in possible depth." The CCP dated January 14, 2011 documented to turn the resident from side to side, not onto his back. The CCP's turning instructions were not documented on the Turning and Positioning Form dated January 2011. This form documented the resident was to be turned and positioned every 2 hours, instructing times for left side, right side, and back. The corresponding signature sheet was signed for 10 of 57 shifts from January 1, through January 19, 2011. The Wound Record documented the pressure ulcer on the resident's right buttock was resolved on January 14, 2011. The Wound Record documented the resident developed a deep tissue injury on his coccyx on January 14, 2011, that measured 2.5 cm x 2.0 cm and was 100% purple. The Turning and Positioning Program record was not signed for 4 shifts for the remainder of the month of January 19 - 31, 2011). The Wound Record, dated January 21, 2011, documented the resident developed: - a new an unstageable pressure ulcer on his Left trochanter (hip) that measured 1.7 cm x 1.0 cm, with 100% white slough tissue in the wound bed; - a recurring Stage II pressure ulcer on the right buttock 0.1 cm x 0.2 cm; - the coccyx Stage II pressure ulcer, measured 3.0 cm x 2.0 cm, with a pink wound bed and purple surrounding tissue. The registered nurse (RN) wound care nurse's note dated January 22, 2011, documented a late entry for January 21, 2011 wound rounds. This note recorded the resident was thin, and all skin preventative measures were in place, including turning and positioning every two hours. The RN recorded the CNA's record was reviewed. (The note did not address the blanks on the CNA's turning and positioning accountability record, or the lack of instructions not to position the resident on his back). The nurse practitioner (NP) orders, dated January 22, 2011, documented treatment for [REDACTED]. The Wound Record dated January 28, 2011, documented the following: - a new Stage II pressure ulcer on the left upper tibia (calf) area that measured 0.7 cm x 0.5 cm, was pink, and superficial; - the left hip, Stage II pressure ulcer measured 1.4 cm x 1.0 cm, with a pink wound bed; - the coccyx, Stage II pressure ulcer measured 2.0 cm x 2.5 cm, with a pink wound bed. The wound care RN's note, dated January 28, 2011, documented the resident was thinner with more prominent bony areas. The note recorded all interventions would be continued and daily care monitored with weekly assessments. The NP order, dated January 28, 2011, documented to treat the resident's left hip, left calf and coccyx with wound gel and border gauze daily. There was no instruction to treat the resident's right buttock. The Treatment Administration Record (TAR) dated January 28, through February 3, 2011, documented to treat the resident's right buttock, coccyx and left hip with wound gel. These treatment were signed by the nurses as being done, and the dressing being in place every shift. The Turning And Positioning Program Form dated February 1, 2011 documented to turn the resident every 2 hours from side to side, and continued to omit the instructions for staff not to position the resident on his back, as specified in the CCP. . The physician's note dated February 2, 2011 documented "Orders for wound care for open coccyx has been given." The Wound Record dated February 4, 2011, documented the following: - the left calf Stage II pressure ulcer measured 0.5 cm x 0.6 cm, with a pink wound bed; - The left hip Stage II pressure ulcer measured 1.1 cm x 0.4 cm, with a pink wound bed; - the coccyx Stage II pressure ulcer measured 3.2 cm x 2.4 cm, with a pink wound bed. The RN Unit Manager's note, dated February 4, 2011 documented the resident was seen on wound rounds, which showed improvement of all wounds "except for coccyx wound slightly larger in size. All wound beds pink. Continue current treatment." The TAR, dated February 4 - 6, 2011, documented to treat the resident's right buttock, coccyx and left hip with wound gel. These treatment were signed by the nurses as being done, and the dressing being in place every shift. The surveyor observed the resident during his dressing changes on February 6, 2011 from 10:30 AM to 11 AM and observed: - no dressing was present on the left hip pressure ulcer. The ulcer had light yellow slough in the, with surrounding red tissue. The licensed practical nurse (LPN) cleansed the wound with normal saline (NS) and applied wound gel and covered the area with border gauze. - no dressings were present on the right buttock pressure ulcer, or the coccyx pressure ulcer. - the resident had been incontinent of stool and the pressure ulcer on the coccyx and buttocks were covered with the stool. - the LPN washed the stool off the ulcers with a wash cloth and water, then wiped the areas with NS on a gauze pad. - the coccyx pressure ulcer was open with yellow slough in the wound bed and the edges were red; the buttocks pressure ulcer was open, with a red wound bed, and 2 areas of yellow slough. - the LPN applied wound gel and a border gauze dressing to the pressure ulcers on the resident's coccyx and buttocks. In an interview with the LPN treatment nurse on February 10, 2011, at 12 PM, she stated she could have used wound cleanser to clean the stool from the resident's open pressure ulcers. She said she was trying to do the dressing change quickly. The TAR dated February 7, 2011 documented to treat the resident's right buttock, coccyx and left hip with wound gel. These treatments were signed by the nurses as being done, and the dressing as being in place every shift. Observations made on February 7, 2011, at 10:45 AM, during the dressing change with the LPN, the RN Unit Manager assessed the wounds as: - coccyx - Stage II pressure ulcer, 3.2 cm x 1.6 cm with a pale pink wound bed and granulating tissue at the edges; - The right buttock pressure ulcer - Stage II 1.1 cm x 1.9 cm, pale pink wound bed, slightly red edges, and the surrounding skin "denuded". During the dressing change, the surveyor interviewed the RN Unit Manager who stated the pressure ulcer on the resident's buttocks was "new". The RN said that February 4, 2011, was her first day doing the pressure ulcer assessments, as there used to be a wound care nurse. She said the resident's buttocks was healed at that time. In an interview with the LPN treatment nurse on February 7, 2011 at 11:05 AM, she stated the pressure ulcer area on the resident's right buttock looked worse today, and that she had been treating the area as directed by the TAR. She said she did not work on Friday, February 4, 2011. In an interview with the RN Unit Manager on February 7, 2011 at 11 AM she stated she did not know the TAR documented to treat the resident's right buttocks. She said there was a 3 person check system for all new physician/NP orders to ensure they were carried out as ordered. Two (day shift) LPNs were interviewed on February 10, 2011 at 2:30 PM. They stated the CNA turning and positioning sheets were checked by them and signed off daily at the end of their shift for compliance. They said sometimes the CNAs left before they got a chance to check the sheets. The day shift CNAs routinely assigned to care for the resident during December 2010 and January 2011 were not available for interview. The RN wound care nurse was not available for interview as she was no longer employed by the facility. In summary, the resident experienced harm, as the resident did not receive the planned care to prevent the development of pressure ulcers, as the facility: - failed to ensure the resident's turning and positioning schedule was consistently followed as planned; - failed to document the change in the turning and positioning schedule until 2 weeks after it was care planned; - failed to cleanse the resident's open pressure ulcer areas in a manner to prevent contamination and infection from exposure to stool. 2) Resident #15 has [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], documented the resident had short term memory impairment; needed total assistance of 2 for bed mobility and transferring; was totally dependent for mobility; required the assistance of 1 for hygiene; and had an indwelling Foley catheter (for urinary drainage). The Braden Scale used for predicting pressure ulcer risk dated December 30, 2010, documented the resident was at moderate risk. The CCP, dated December 30, 2010, documented the following interventions: - turn and position the resident, using a wedge pillow, every 2 hours and as needed; - a gel cushion in the Geri-chair; - keep clean and dry; - use a barrier cream twice a day and as needed; - use a pressure reduction mattress. The CCP did not document the resident was resistive to turning and positioning off his back. The CCP documented on January 14, 21, and 28, 2011, the resident's buttocks were closed and intact. The January 14, 2011 entry on the CNA Assignment/Accountability Record documented to use peri wash and apply peri guard to the resident's buttocks every shift with care and after each episode of incontinence. The wound care nursing note, dated January 28, 2011, documented the resident did not allow turning and positioning side to side, at times. An alternating mattress was to be considered and they would follow in 2 weeks. Interventions and protective cream to buttocks were to continue. The Turning and Positioning record dated January 1 -31, 2011, documented the resident was to be turned and positioned every 2 hours. The co-responding signature sheet was not signed consistently, and when signed, the resident was documented to often refuse to be turned off his back. The Turning and Positioning record dated February 1 - 4, 2011, documented the resident was to be turned and positioned every 2 hours side to side. The co-responding signature sheet did not consistently document the resident was turned off his back every 2 hours. The Wound Record dated February 4, 2011 documented the resident developed 2 areas of denuded skin (the top layer of skin is off) on his left buttock. Site A measured 3.0 x 1.6, and site B measured 1.0 x 0.4 (no unit of measurement written). The area for treatment was left blank. The record documented the resident's right buttock had a denuded area, measuring 1.1 x 0.4 (no unit of measurement written). The treatment administration record (TAR) dated February 4 - 6, 2011, documented to cleanse the resident's buttocks with peri wash, pat dry, every shift and as needed. The TAR dated February 7, 2011, documented, "Cleanse, pat dry, apply skin prep to peri wound area (right and left buttock) apply wound gel to bed cover with [MEDICATION NAME] change daily." The telephone physician's orders [REDACTED]. During an observation of the treatment to the resident's denuded areas on the buttocks on February 7, 2011 at 2:35 PM, the following observations were made: - the resident was on a pressure reduction mattress, (not alternating air mattress); - there was no dressing on the buttocks; - both buttocks had defined open areas, red base, with bright red drainage visible on the incontinent pad. During the observation on February 7, 2011 at 2:35 PM when the nurse practitioner (NP) assessed the resident's open areas on the buttocks, she told the surveyor the resident had "several Stage II pressure ulcers." The NP said the resident needed an alternating air mattress. At 2:50 PM on February 7, 2011, the registered nurse (RN) Unit Manager measured the open, draining Stage II pressure ulcers as follows: - Left buttock, site A, 1.3 centimeters (cm) x 0.4 cm and site B, 3.0 cm x 0.9 cm. - Right buttock, site A, 2 cm by 0.4 cm and site B, as 0.7 cm x 0.3 cm. In an interview with the RN Unit Manager on February 7, 2011 at 2:55 PM, she stated when she saw the denuded areas on the resident's buttocks on February 4, 2011 she spoke to the physician and took a verbal order to treat the areas with wound gel. The RN stated she then got busy with another matter and asked the LPN to write the order. The RN said the order never got written until she wrote it on February 7, 2011 (3 days after it was given). She stated the resident did not receive the treatment until February 7, 2011 and said the areas on the resident buttocks looked worse than on February 4, 2011. The Wound Record dated February 7, 2011, documented the resident had 2 area of denuded skin on his left buttock. Site A was 3.0 x 0.9 (no unit of measurement written) and site B was 1.3 x 0.6 (no unit of measurement written). The wound appearance was red, with "bloody" drainage. The treatment was recorded as wound gel. The record documented the resident had 2 denuded areas on his right buttock site C measure 1.7 x 0.7 (no unit of measurement written) and site D measured 1.1 x 0.3 (no unit of measurement written). The wound appearance was red with "bloody drainage." The NP note dated February 7, 2011 documented the resident had a denuded area to buttocks "most likely Stage II", will follow the physician's orders [REDACTED]. In an interview with the physician on February 10, 2011 at 10:30 AM, she stated she gave verbal orders at times, but did not remember giving the verbal order to treat the resident's buttocks on February 4, 2011. The RN Wound Care Nurse was not available for interview, as she was no longer employed by the facility. The resident was observed in bed on his back, there was no alternating air mattress on the bed the following times: - February 8, 2011 at 9:30 AM, 10 AM, 11:45 AM, and 1:30 PM. In an interview with the NP on February 10, 2011, at 10:30 AM, she stated they could not find an alternating air mattress for the resident. She said that there had been a meeting last evening, and one would be put on the resident's bed this morning. On February 10, 2011 at 4:17 PM, the resident was observed lying on his back in his bed. There was no alternating air mattress on the bed. In summary, the resident experienced harm, as the facility failed to ensure the resident received care and services to prevent the development of 4 Stage II pressure ulcers on his buttocks. The facility: - failed to provide an alternating air mattress as recommended on January 28, 2011, or provide a rationale for not doing so; - failed to treat the residents denuded skin areas as ordered by the physician for 3 days, and the areas developed into Stage II pressure ulcers; - failed to ensure the resident's turning and positioning schedule was consistently implemented; - failed to develop and implement a care plan regarding the resident's resistance to turning and positioning off his back. 5) Resident #10 had [DIAGNOSES REDACTED]. The resident's Nursing Admission Assessment, dated January 21, 2011, documented the resident had no identified skin impairment/pressure ulcers, and had a low risk for the development of pressure ulcers. The CNA Assignment/Accountability Record (guidance used for direct care staff), initiated January 21, 2011, documented the resident was to have his brief changed every 2 to 4 hours, and had Nutrashield (protective ointment) applied to his buttocks twice a day, with morning and evening care. On January 24, 2011, the resident's Nutritional Assessment documented the resident's [MEDICATION NAME] was 3.1 g/dl (2.8 to 3.5 grams per deciliter reflected mildly depleted [MEDICATION NAME] level). The comprehensive care plan (CCP), updated January 24, 2011, documented the resident was independent with bed mobility, required total assistance and use of a mechanical lift for transfers, and required extensive assistance with personal hygiene. On January 24, 2011, the occupational therapist documented the resident transferred from his wheelchair to the mat and back with a slide board and a maximum assist of 1 person. The resident's Admission History and Physical, dated January 26, 2011, documented the resident had no rashes/itching, and his skin turgor was fair. The physician's plan did not document preventive skin interventions. The resident's Minimum Data Set (MDS) assessment, dated January 26, 2011, documented the resident was independent in decision making and bed mobility, and required total assistance of 2 for transfers. The MDS documented the resident was at risk to develop pressure ulcers, had pressure relief in his bed/chair, and had preventive ointments other than to his feet. Physical therapy (PT) notes, dated January 28, 2011, documented the resident transferred with maximum assist of 1 staff for sliding board transfers; practiced pulling to either side as a lead up to bed rolling/mobility; and documented the resident was fitted with a narrow wheelchair with a high back/recliner function. A facility Interdisciplinary Resident Communication form, dated January 30, 2011 and signed by a registered nurse (RN) supervisor, documented the resident developed a 1.0 centimeter (cm) x 0.5 cm Stage II ulcer on his right buttock, and a Wound Record was initiated. The form was sent to Nursing, PT (physical therapy), Dietary, and copied to the registered nurse (RN) Unit manager, the RN in charge of the wound/skin team, and the Director of Nursing (DON). On January 31, 2011, PT notes documented the resident used the sliding board for transfers with a moderate assist of 1, and a minimum assist of 1 while in therapy. There was no documentation related to the resident's pressure ulcer. The resident's Wound Records documented the resident developed a new a Stage II pressure ulcer, identified on January 31, 2011, on his right buttock, that measured 1 centimeter (cm) x 0.5 cm, with a "pink" wound bed. On January 31, 2011, a telephone order was obtained from the facility nurse practitioner (NP) for Sensicare every day to the "denuded area" on the resident's right buttock. Dietary notes on January 31, 2011 documented she was aware of the resident's new Stage II "area". Ensure was added twice a day, and 2 Cal HN was added twice a day for additional calories. The resident's caloric needs were increased due to his wound, protein needs were increased due to a low [MEDICATION NAME] and his wounds, and fluid needs were increased in part due to his increased protein needs. On February 1, 2011, the Wound Records documented the resident had a Stage II pressure ulcer on his right sacrum, which measured 1 cm x 0.5 cm; a second Stage II on his right sacrum which measured 4.5 cm x 4.5 cm; and a Stage II on his left sacrum which measured 1.5 cm x 2.3 cm. The pressure ulcers were newly identified, the wound beds were pink/red, and Sensicare was the treatment implemented. On February 1, 2011, the physician ordered Sensicare (protective barrier ointment) to the resident's sacrum every shift. The order documented nursing staff were to cleanse the sacrum with soap and water, apply the Sensicare, and apply Nutrashield to the intact skin. The CNA Assignment/Accountability Record, revised February 2, 2011, documented the resident was to be turned and positioned side to side in bed every 2 hours. On February 3, 2011, Wound Records documented the resident's Stage II right buttock pressure ulcer measured 1 cm x 0.5 cm (unchanged), wound bed remained pink, and Sensicare was the treatment implemented. PT notes documented that on February 2, 3, and 4, 2011, the resident used the sliding board for transfers during therapy. The CCP, dated February 4, 2011, documented the resident had 4 pressure ulcers, 1 on his left buttock, 1 on his right buttock, and 2 on his sacrum. The CCP documented the resident had an alternating air mattress, should be turned and positioned every 2 hours and as needed, and should have a pressure reduction cushion in his chair. There was no documentation related to the frequency of repositioning when he was in his chair, or pressure relief for his heels. When interviewed on February 8, 2011 at 4:40 PM, the RN Unit Manager stated the CCP related to the resident's new pressure ulcers was initiated on February 7, 2011, not February 4, 2011 as documented on the CCP. She stated February 7, 2011 was the day she called for/received the resident's alternating air mattress. During a wound observation on February 8, 2011 at 9:25 AM, the resident was on his back in bed, an air mattress was underneath him, and his heels were resting on the mattress. The resident had 4 pressure ulcers, on his left and right sacrum and coccyx; all were superficial open areas, with a pink/red wound bed. A new reddened non-blanchable area was observed on the resident's left heel. Wound Records, dated February 8, 2011, documented the resident had a new Stage I pressure ulcer on his left heel which measured 0.5 cm (circular), was pink, and non-blanchable. On February 8, 2011 at 10:30 AM, the resident was observed in bed on his back with his heels resting on the mattress. When interviewed on February 8, 2011 at 11:55 AM, the RN Unit Manager told the surveyor that PT was not involved in the prevention of skin ulcers. The RN Manager stated nursing was responsible for the resident's plan of care, and nursing would contact physical therapy if a different cushion was needed for a resident's chair. During an interview on February 8, 2011 at 1:25 PM, the facility NP stated the physician completed the resident's admission history and physical, and it had been "very difficult" for her to participate in wound/skin rounds on the nursing unit as she had been busy with other work. The NP stated the RN, who had been in charge of the wound/skin rounds and was no longer at the facility, would review the results of rounds with the NP, and the NP would write orders as needed. The NP stated the physical therapist was responsible for completing an evaluation, and made recommendations "as appropriate". The NP stated the RN Unit Manager completed the initial skin assessment and was responsible for implementing preventive interventions. The NP said any discipline could notify her of their concerns and she would follow up. The resident was observed in his chair in his room on February 7, 2011 at 3:35 PM and 5:10 PM; and on February 8, 2011 at 11:50 AM and 2 PM. The occupational therapist (OT) was interviewed February 8, 2011 at 12:05 PM and stated she advised the resident not to sit in his chair with a pillow behind his back, and did not make recommendations on the length of time the resident should sit in the chair. During an interview on February 7, 2011 at 5:10 PM, the RN manager stated the resident usually stayed up in his chair "all day". When interviewed on February 9, 2011 at 11:30 AM, the facility's 2 PTs stated they had not been notified the resident had pressure ulcers. One of the therapists stated if they had known, they would have recommended a different cushion for his chair, and would have evaluated whether they should wait to work with him in using a slide board for transfers. They stated the resident had a high back wheelchair that could be raised and lowered to change pressure points when he was in his chair. They stated they had not educated nursing staff on repositioning the resident in his chair. Both PTs stated they were not part of the wound/skin team. During a wound observation on February 15, 2011 at 12:30 PM, the RN Unit Manager stated the ulcers were "merging together" and "appear worse", since she last observed them on February 10, 2011. The RN Unit Manager's progress note, dated February 15, 2011, documented the resident's 4 Stage II pressure ulcers on his buttocks and sacral areas were "merging", the wound bed was 50% slough, and the remainder of the wound bed was pink tissue with a scant amount of bloody drainage. On February 16, 2011, the resident's Wound Records documented the resident's left heel pressure ulcer resolved; and one of the resident's right sacrum pressure ulcers measured 0.6 cm 0.8 cm (unchanged), and the wound bed remained pink. The Wound Records documented the resident's Stage II left sacrum and the second right sacrum pressure ulcers had merged with the Stage II right buttock pressure ulcer, which measured 1.0 cm x 0.6 cm (smaller area for all three as compared to February 10, 2011), and the wound bed was 50 percent slough (right sacrum area) and the rest remained pink. Sensicare continued as the treatment for [REDACTED]. During a phone interview with the physician on February 16, 2011 at 11:45 AM, the physician stated he was not aware the resident had pressure ulcers. This conflicted with the order he gave on February 1, 2011 for Sensicare ointment to the pressure ulcers. The NP was present at the time of the phone interview, and told the surveyor she planned to assess the resident's pressure ulcers on that day, as the RN manager had notified her the ulcers had deteriorated. In summary, the resident experienced harmed, as the facility: - failed to ensure medical staff evaluated the resident's pressure ulcers in a timely manner. - failed to ensure therapy staff were notified of the resident's pressure ulcers, and failed to evaluate his plan of care, related to the development of pressure ulcers; - failed to ensure nursing staff were educated by therapy staff on the importance of repositioning the resident when he was in his wheelchair. 10NYCRR 415.12(c)

Based on record review, observations and staff interviews conducted during the partially extended abbreviated survey (#NY 391 and #NY 983), it was determined the Administrator failed to ensure the facility was administered in a manner that attained or maintained the highest practicable physical well-being of 9 (Residents #1, 3, 4, 10, 13, 14, 15, 16, and 18) of 18 residents reviewed with skin concerns and failed to ensure the facility operated in a manner in which professional standards of quality were maintained, and failed to ensure a pressure ulcer deficiency (refer to F314) did not recur as originally cited in the October 22, 2010 recertification survey. Specifically, the Administrator failed to ensure qualified professional staff performed assessments of residents with skin breakdown in order to prevent the the deterioration and promote healing; failed to monitor residents with skin breakdown; and failed to ensure treatments were provided consistently and timely. This resulted in actual harm that is Substandard Quality of Care and not Immediate Jeopardy for Residents #1, 3, 4, 10, 14, and 15, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #13, 16 and 18. Refer to F309 and F314 Findings include: During an interview on January 21, 2011 at 2:00 PM, the Assistant Director of Nursing/Wound Care Nurse (ADON/WCN) stated that a full body audit was not completed at the time of the weekly wound care rounds. If a new area was found the Registered Nurse/ Unit Manager (RN/UM) was responsible for initiating a wound record for follow-up by the wound care team. She stated the wound care team did not follow residents with rashes, excoriated or denuded skin areas, as those are followed by the Nurse Practitioner (NP). During an interview on January 31, 2011 at 12:10 PM, the NP stated that she gave a verbal order for Resident #1 for [MEDICATION NAME] cream (used to protect skin from moisture and irritating substances) to bilateral buttocks twice a day and as needed. She added that she had not see the status of the resident's buttocks. The Administrator was interviewed on January 31, 2011 at 1:35 PM regarding Resident #1's skin integrity. The Administrator stated he was waiting to hear from the family regarding the condition of the resident's skin when he arrived at the hospital on January 12, 2011. The Administrator stated no one from the facility called the family to provide the resident's requested medical records. At 10 AM on February 7, 2011, the Administrator told the surveyor he did not attend the facility's morning "clinical" report when the contents of the 24-hour nursing report and other resident issues were discussed. 10NYCRR 415.26 (a)(1)

Based on record review and staff interviews conducted during the partially extended abbreviated survey (#NY 391 and #NY 983), it was determined the facility's governing body failed to establish and implement policies regarding the management and operation of the facility to ensure the facility was managed in a manner that protected the health of 8 (Residents #1, 3, 4, 13, 14, 15, 16, and 18) of 18 sampled residents reviewed for skin concerns. This resulted in actual harm that is Substandard Quality of Care, and not Immediate Jeopardy for Residents #1, 3, 10, 14, 15, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #13, 16 and 18. Refer to F281, F309 and F314. Findings include: The facility's Governing Body failed to ensure the facility's administrative staff, (including the Administrator, Director of Nursing and Medical Director), and Quality Assurance (QA)committee, established and implemented polices to prevent a repeat deficiency in pressure ulcers (refer to F314), as originally cited in the October 22, 2010 recertification survey. The Governing Body failed to ensure residents with wounds (including Residents #1, 3, 4, 13, 14, 15, 16, and 18) received timely assessments, consistent and timely monitoring, effective and timely skin treatments to prevent deterioration and promote healing (refer to F309, F314); and failed to ensure facility staff adhered to professional standards of quality when conducting skin assessments, and when completing medical record documentation. 10NYCRR 415.26 (b)(3)(4)

Based on record review and staff interviews conducted during the partially extended abbreviated survey (#NY 391 and #NY 983), it was determined for 8 (Residents #1, 3, 10, 13, 14, 15, 16 and 18) of 18 sampled residents reviewed for skin concerns, it was determined the facility failed to ensure the Medical Director (MD) provided the oversight in the development, implementation, and evaluation of the effectiveness of their wound and skin care policies and procedures, affecting all residents with compromised skin integrity. Specifically, the MD failed to assist in the development and implementation of an effective skin and wound care program in the facility; failed to provide the clinical oversight of medical staff to ensure medical staff assessed residents' wounds and skin breakdown and consistently monitored the effectiveness of their treatment regimens. This resulted in actual harm for Residents #1, 3, 4, 10, 14 and 15 that is Substandard Quality of Care and not immediate jeopardy, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for residents #13, 16 and 18. Refer to F281, F309, and F314. Findings include: The surveyor conducted a telephone interview with the MD on February 14, 2011 at 3:40 PM regarding when staff should notify physicians, if he was involved in developing facility policies, and was he aware of the facility's policies on skin integrity (assessing, monitoring, treating, and evaluation of preventative and treatment plans.) The MD stated an attending physician should be notified by the facility of "any acute changes in a resident's status." He stated 2 attending physicians covered for each other and one of the facility's Nurse Practitioner (NP) covered the other attending physician's residents. The MD stated he was not the attending physician for the facility's residents. He stated he was not aware of facility policies for excoriated or "denuded" skin, or of a policy for "verbal orders" and telephone orders." He said "verbal orders were discouraged; nurses and physician are asked not to do this" practice. The MM stated he did not provide oversight to the facility's NP; it was up to the "agreement" with the attending physician. He also said "at the present time", he was not involved with the facility's skin care programs. During an interview regarding facility practice for monitoring their residents' skin status, on January 21, 2011 at 2:00 PM, the Assistant Director of Nursing/Wound Care Nurse (ADON/WCN) stated a full body audit was not completed during weekly wound care rounds. If a new skin area was found, the unit manager was responsible for initiating a Wound Record for follow up by the wound care team. The ADON/WCN stated the wound care team did not follow residents with rashes, excoriated, or denuded skin, as those areas were followed by the NP. When Resident #1's status was discussed, the ADON/WCN stated she found out his skin issues when she went to the hospital to observe his wounds. She stated she completed skin status notes Wound Record and Comprehensive Care Plan (CCP), dated for January 6, 2011 and January 13, 2011, after her visit with the resident at the hospital. That was the first time, she said that she learned of the resident's coccyx, peri-area and scrotum wounds. On January 31, 2011 at 12:10 PM the NP was interviewed who stated Resident #3 had stasis ulcers on his lower legs, and the attending physician transferred him to the hospital for possible [MEDICAL CONDITION]. She stated she was notified by staff on 1/1/11 of the resident's buttocks being denuded and macerated due to frequent incontinence. The NP stated that she gave a verbal order for [MEDICATION NAME] cream (used to protect skin from moisture and irritating substances) to the bilateral buttocks bid and prn. She stated that as of the day of the interview she had not seen the status of the resident's buttocks. In an interview on February 8, 2011 at 11:05 AM, the attending physician told the surveyor she did not assess Resident #3's legs, or other areas of the resident's skin, when she saw him, as her focus was to transfer him to the hospital for evaluation of his abnormal lab reports and his renal status. At 11:25 AM on February 8, 2011, the attending physician agreed to assess the resident's wounds and lower extremities. The attending physician noted a dime size area of firmness, Stage I over the bony prominence on the lateral aspect of his right foot with no surrounding erythremia or weeping. Another small area was present on the lateral aspect of his left foot beneath. The physician did not have the resident's lower legs unwrapped (wrapped with Ace bandages). In summary, the facility: - failed to ensure the Medical Director assisted in the development and implementation of an effective skin and wound care program in the facility; - failed to ensure the Medical Director provided clinical oversight of medical staff to ensure they assessed residents' wounds and skin breakdown and consistently monitored the effectiveness of their treatment regimens. 10NYCRR 415.15 (a)(1)(2)(4)

Based on observations, record review and staff interviews conducted during the partially extended abbreviated survey (#NY 391 and #NY 983), it was determined the facility failed to have a Quality Assurance (QA) program in place that effectively identified issues to prevent repeat deficiencies and maintain compliance with State and federal regulations, affecting 8 (Residents #1, 3, 4, 13, 14, 15, 16, and 18) of 18 sampled residents reviewed for skin concerns. Specifically, the facility's QA committee failed to ensure a pressure ulcer deficiency (refer to F314) did not recur as originally cited in the October 22, 2010 recertification survey; failed to ensure residents with wounds received the assessments, care and services to needed to promote healing (refer to F309); and failed to ensure facility staff adhered to professional standards of quality when conducting skin assessments, fall assessments, and when completing medical record documentation (refer to F281). This resulted in actual harm that is Substandard Quality of Care and not Immediate Jeopardy for Residents #1, 3, 10, 14, 15, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #13, 16 and 18. Refer to F281, F309, and F314 Findings include: On February 7, 2011 at 10 AM, the surveyor interviewed the Director of Nursing (DON). During the interview, the surveyor asked the DON about the problems with documentation on residents' status and their care. The DON stated there was no policy regarding documentation requirements on the Certified Nursing Assistant (CNA Assignment/Accountability Records. She stated they were "all trained and know this expectation." At 10:30 AM on February 7, 2011, another surveyor interviewed the DON at 10:10 AM regarding the turning and positioning of residents and this documentation. The DON stated the CNAs, Licensed Practical Nurses (LPNs) and Registered Nurse/Unit Managers (RN/UM) are all responsible. She stated these "records were checked once a week, including the Medication Administration Records (MARs), the Treatment Administration Records (TARs), (for example) "to see what is going on." The DON stated the facility's "standard was expected" to be followed. The DON stated if there were "issues", they "should go up the chain of command" for "disciplinary actions." When the DON was interviewed on February 15, 2011 at 11:10 AM, she stated she first learned of incorrect information regarding Resident #3's initial skin assessment on January 25, 2011, and the Assistant Director of Nursing's (who previously functioned as the facility's wound care nurse) inaccurate documented wound rounds. The DON stated she "did not ask anyone to re-assess" Resident #3's skin after learning of the documentation errors. In summary, the facility's QA committee: - failed to ensure a pressure ulcer deficiency (refer to F314) did not recur as originally cited in the October 22, 2010 recertification survey; - failed to ensure residents received timely skin assessments, care and services to promote healing (refer to F309); - failed to ensure facility staff adhered to professional standards of quality when conducting skin assessments, and when completing medical record documentation (refer to F281). - Refer to F 281, F309, F314. 10NYCRR 415.27 (a)(c)(3)(i,ii,iv,v)(4)

Surveyor: Dempsey, Patricia J. Based on record review, staff and resident interviews, and observations conducted during an abbreviated survey (#NY 902 and #NY 521), it was determined the facility did not ensure 2 (Residents #1 and 2) of 3 residents reviewed for quality of care received appropriate treatment and services for their psychosocial difficulties. Specifically, Resident #1 did not receive psychological treatment for one month, after returning from a hospitalization for attempted suicide, and required an acute psychiatric admission after expressing intent to harm herself. Resident #2 was not provided with all the care plan specified interventions to address her ongoing feelings of anger regarding placement and her sadness over the loss of a friend; and provided no documented rationale for not implementing the psychiatrist's medication recommendations. This resulted in actual harm that is not immediate jeopardy for Resident #1, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #2. Findings include: 1) Resident #1 has [DIAGNOSES REDACTED]. The medical record contained a letter from IPRO (independent health care organization) approving the resident's placement in the facility, dated July 17, 2009; and her needs could be met at the facility. The Minimum Data Set 3.0 (MDS) assessment, dated October 23, 2010, documented the resident was alert and oriented. The resident's mood "nearly every day", was described as having little interest in doing things; felt down, depressed; felt tired, had little energy. A psychological services note, dated November 1, 2010, documented the resident had nightmares and "[MEDICAL CONDITION]", but was unable to provide additional information. "Appears to be present with cognitive slowing." The note documented the resident had little response to interventions. The nurse practitioner's (NP's) note, dated November 5, 2010, documented the resident was seen for increased anxiety, and stated "I want to die, I want to cut myself with a big knife." When asked why, the resident stated she was always hungry and did not want to live like that. The NP specified the resident was re-directed with discussion about her diet and was given [MEDICATION NAME] (an anti-anxiety medication). The note documented the resident's statement was more behavioral, and specified the resident was not actively suicidal. The psychologist's note, dated November 8, 2010, documented the resident had fatigue with sleep difficulties. This note recorded the resident's self-injurious statements were discussed. The resident denied current ideation, had limited insight, and was withdrawn when questions were difficult. The documented rationale for ongoing treatment was to improve sleep functioning. A nursing note, dated November 17, 2010 at 2 PM, documented the resident brought herself out of her room with her dress on fire. The note specified another resident put the fire out and alerted staff. The resident was found to be alert and oriented, and made statements that she wanted to die. When asked, she stated she just did not want to live. The accident/incident report, dated November 17, 2010 at 2 PM, documented the resident was "seen by another resident" to be "on fire". "Wanted to burn herself to death. Another resident put fire out with his hands. Large burn hole noted on resident's dress." The report documented the resident was sent to the hospital emergency room . The resident's room was searched and a lighter was found. The licensed practical nurse's (LPN) written statement, dated November 17, 2010, documented the resident set herself on fire with a lighter (found in her purse after the incident). Another resident found her on fire and put the fire out. This LPN's statement recorded the resident said she wanted to die and burn herself. The resident's statement, dated November 17, 2010 and signed by the registered nurse (RN) Unit Manager, was "I wanted to kill myself." When the RN Unit Manager was interviewed on December 21, 2010 at 2:45 PM, she stated the resident was not known to be a smoker. She said the resident got the lighter from her family, when they visited. The RN stated it was the first time the resident was found with contraband; and said the resident was currently on room checks every shift for contraband. The resident's hospital discharge summary, dated November 19, 2010, documented the resident's [DIAGNOSES REDACTED]. This note documented the resident denied any suicidal plan when evaluated by "psych" service. The resident acknowledged difficult adjustment, depressed mood, and dysthymic mood (chronic depression). "Per psych evaluation, the patient makes threats of self injury only in the context of secondary gain and attempt at manipulation for change in housing. Per the patient, if I have to live there, I will go back, I will hurt myself." The discharge report documented the resident identified neuropathic (nerve) pain as the most difficult stressor. "Per psych service, the patient could be discharged back to the nursing home for nursing and rehabilitation. The facility was recommended to keep the (resident) under 1:1 observation, until evaluated by psych service at the nursing home." Recommendations included increasing [MEDICATION NAME] (an anti-depressant) to 120 milligrams per day over time, to help with depression and [MEDICAL CONDITION] (nerve pain). [MEDICATION NAME] (medication for [MEDICAL CONDITION]) increased to 800 mg twice a day to help stabilize mood, reduce anxiety, and provide some sedation. The recommendations included: supportive therapy at the nursing home to assist with adjustment; a "psych" evaluation when she arrived at the nursing home; and 1:1 observation until assessed by psychiatry. An addendum to the hospital discharge summary, dated November 22, 2010, documented the resident's discharge was cancelled, as the nursing home declined to accept the resident on 1:1 observation. "The patient was re-evaluated by psychiatric service today. She was not considered suicidal or homicidal. Her 1:1 was discontinued, and she was deemed safe to be discharged to a nursing home, with psychiatric follow-up." The hospital psychiatrist's note, dated November 23, 2010, documented the resident's mood was tranquil until the nursing home's name appeared in conversation. At that point, the resident stated "I am not returning there; I don't want to live there anymore." The note documented the resident stated if she returned to the facility, she would try to kill herself. "Apart from that, she voices no suicidal ideas or plans, remains content in the hospital." This note specified the resident had no signs of [MEDICAL CONDITION], manic or hypomania, and no symptoms of [MEDICAL CONDITION]. The note documented the resident had no signs of decompensation or exacerbation of a mental disorder, other than the distress from adjusting to living at the nursing home. The recommendations were for outpatient psychiatry, increased contact with psychiatry, and increased contact with the nursing home's social worker, to assist in the resident's adjustment to the facility. The hospital discharge summary, dated November 24, 2010, documented the resident had uncontrolled type II diabetes, suicidal ideation, [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] and low back pain. This report directed to "please see the previous discharge summary", as well as the addendum. Nursing notes, dated November 24, 2010 at 9 PM, documented the resident returned to the facility. The comprehensive care plan (CCP), dated November 24, 2010, documented the resident returned from the hospital, and the medications were appropriate after her psychiatric evaluation for attempted suicide. The CCP's interventions specified psychology consult as needed, or as ordered by the physician; the resident was placed on 15 minutes checks for suicide watch; and room checks every shift. review of the resident's medical record revealed [REDACTED]. The physician's note, dated November 29, 2010, documented the resident obtained a lighter, set her clothes on fire, and was sent to the hospital. The note specified the "Discharge summary from the hospital is not available, so it is unclear what her psych evaluation consisted of." The physician documented the resident was maintained on 15 minute checks since her return. The physician noted the resident had no significant behavioral problems since her return. The physician's plan included "she will be followed by psychiatry." Continue to monitor. The CCP, dated December 9, 2010, documented the resident continued to appear sad, and hoped to move close to her family. A nursing note, dated December 16, 2010 at 10 PM, documented the resident was discontinued from the 15 minute checks. In an interview on December 22, 2010 at 4:30 PM with the RN who wrote the verbal order to discontinue the resident's 15 minute checks, he stated someone called him from the resident's unit and asked him to get the order from the psychiatrist. The psychiatrist was on the RN's unit at that time. The RN took the order and wrote it in the resident's chart. The RN stated he did not see the psychiatrist examine the resident before giving the order. Nursing notes, dated December 17, 2010, documented dietary was notified of the change in suicidal precautions, and the resident was to "start receiving regular dinner utensils; no paper products." The CCP was updated on December 17, 2010 with this information. The CCP, dated December 19, 2010, documented the resident complained of increased leg pain; "my [MEDICAL CONDITION] is killing me". The NP was updated and ordered [MEDICATION NAME] (a narcotic pain reliever) and [MEDICATION NAME] (anti-anxiety medication) for 1 dose. The CCP specified the NP was to address increased complaints of pain and possibly increasing the [MEDICATION NAME]. When the surveyor reviewed the resident's medical record on December 21, 2010, there was no documented evidence the resident was seen by psychiatry, psychology or the social worker, to address her behavior or her adjustment to the nursing home. There was no documented evidence the recommended medication changes (on the hospital discharge plan) were addressed; and no documented rationale for not implementing the change in medications. In an interview with the charge LPN on December 21, 2010 at 1:45 PM, he stated the resident had not been seen by the psychologist, since she set her clothing on fire. He said he was not sure why psychological services were discontinued. The LPN stated the resident had a verbal order on her chart from the psychiatrist to discontinue the 15 minute checks. He stated the resident had been good; had no behavior outbursts or inappropriate behavior; and no suicidal ideation occurred since her return. The LPN said the resident came out of her room for meals and had a friend (another resident) who spent time with her in her room. During the surveyor interview with the RN Unit Manager on December 21, 2010 at 1:45 PM, the RN stated the resident was on the psychiatrist's list to be seen after her return from the hospital. She stated the resident was also on the list to be discussed at the behavior management meeting after her return, and would be discussed at "tomorrow's meeting" (December 22, 2010). The surveyor interviewed the social worker on December 21, 2010 at 2 PM. She stated she was the only social worker for the facility at that time. She said she had contact with the resident on a "pretty regular basis", although she just started her employment "4 weeks ago". The social worker stated she assisted the resident with getting some personal items she requested. She said she was unaware of the hospital psychiatrist's recommendations to increase contact with the resident, to assist with her adjustment to the facility. In a telephone interview with the resident's attending physician on December 22, 2010 at 11:10 AM, she stated psychiatry follow-up for residents on the behavior unit was included in their "intake" into the unit; and the resident was under the care of a psychiatrist. The physician stated her impression of the resident was that she was increasingly withdrawn, with increased somatization (persistent complaining of varied physical symptoms with no identifiable origin), that in the past, corresponded with increased depression. The physician stated the resident was seen in the past by 2 different psychologists, and was not being seen on a weekly basis, because of a "low supply of services with high demand." The physician said the psychiatrist came by "without a lot of prior warning", and tried to see as many people as he could. The surveyor observed the resident on December 22, 2010 at 11:10 AM, lying in bed, awake and alert. The resident told the surveyor she was having a "bad day", because the nurses "won't let me eat what I want." The resident stated she wanted to leave the behavior unit, because she did not belong there. The NP was interviewed on December 22, 2010 at 11:50 AM, and stated there was no set plan to ensure everyone on the behavior unit was seen regularly by the psychiatrist. The NP said Resident #1 was fine since her return from the hospital on November 24, 2010. The NP stated the resident was scheduled to be discussed at the behavior meeting that day (December 22, 2010). In an interview with the Administrator and the Director of Nursing (DON) on December 22, 2010 at 3:10 PM, they stated the psychiatrist came in the evening and saw the residents with consults that needed to be done. They stated the psychiatrist did not always see everyone on the list; and he did not always show up when they expected him. The psychiatrist did not respond to a telephone message left on December 22, 2010 at 1:05 PM, and January 4, 2010 at 9:48 AM. When the psychiatrist was reached and interviewed on January 10, 2011 at 10:30 AM, he stated the facility would give him a list of residents to be seen. He said they expected him to see all of the residents on the list, and that it was an unrealistic workload. The psychiatrist stated he tried to prioritize the residents he saw, by discussing them with the nurse managers on the units. He said he was recently provided with a letter that his services were no longer needed at the facility. After the surveyor's discussion with the Administrator on December 22, 2010 at 3:15 PM, the Administrator documented a separate typed note that specified the psychologist would provide a psychology consult for this resident. The psychologist's note, dated December 22, 2010 at 4:40 PM, documented the resident seen to assess her for depression and suicidal ideation. The resident stated she had "suicidal ideation with intent, but no coherent plan." The resident agreed to a voluntary admission to the hospital at that time and transportation was arranged. The NP's note, dated December 22, 2010, documented the resident stated she was going to harm herself, and had a plan. The NP wrote an order, dated December 22, 2010 at 5 PM for the resident to be transported for an acute psychiatric hospital admission. In summary, Resident #1 experienced harm, as she required an acute psychiatric hospital admission, as the facility: - did not provide the recommended psychiatric, psychological or social service follow-up after her November 2010 hospitalized for [REDACTED]. - did not implement the recommended medication changes, per hospital discharge summary, or provide a documented rationale for not doing so. - did not develop and implement a plan to assist the resident with her adjustment to the nursing home and behavior unit. 2) Resident #2 had [DIAGNOSES REDACTED]. The most recent psychiatric evaluation, dated May 7, 2010, documented the resident was alert, had paranoid ideation, depression, helpless feelings, and sleep disturbance with difficulty falling asleep. The evaluation recorded the resident had temper issues with sporadic agitation, and dysphoric (depressed) mood. She was legally blind, hypersensitive, and disinhibited with an underlying mood dysregulation, superimposed on anxiety and depression. The [DIAGNOSES REDACTED]. The recommendations were to start [MEDICATION NAME] M-tab (an anti-psychotic medication) 1 milligram twice a day and supportive therapy. The Minimum data Set (MDS) 3.0 assessment dated [DATE], documented the resident had little interest or pleasure in doing things on several days and thoughts that she would be better off dead or hurting herself. The resident had verbal behavioral symptoms directed toward others at times (1-3 days), and rejected evaluation or care at times (1-3 days). This assessment documented the resident was cognitively intact. The most recent psychology note dated October 15, 2010, documented the resident was referred because she made the statement she would be better off dead. This note recorded the resident denied suicidal ideation or intent, but did say her life "was not good." She missed her male friend and believed she should be discharged so she could have her own place. Discussion concerning long term care was met with anger and resistance. There was no documented evidence of recommended interventions to assist the resident with coping with her adjustment or anger. The mood state assessment, dated October 25,2010, documented the resident had a recent change in relationships; as a friend was in the hospital. This assessment documented the resident received [MEDICATION NAME] for anxiety. The comprehensive care plan (CCP) dated October 25, 2010, documented the resident was was verbally abusive, socially inappropriate, resisted care, used vulgar language, had anxiety, was uncooperative and hostile; had conflict with, or repeated criticism of, staff, and openly expressed anger. The CCP also specified the resident might decide to leave the facility against medical advice to return to her house. Interventions included: to encourage the resident's participation in activities; provide a psychology consult per physician order; observe and report behaviors; check the resident for unmet needs; regularly assess discharge potential; and engage the resident in discharge plan of care. "Team will continue to help resident adjust, or work with resident for safe discharge." The most recent interdisciplinary team meeting note, dated October 25, 2010, documented the resident was very non-compliant with various parts of her care plan; often unpleasant and difficult to get along with. The note documented the resident refused activities and yelled at the staff when they offered. The team note specified the resident preferred to lie in her bed, or smoke. The team documented the resident could benefit from rehabilitation, "but was not cooperative." Review of the certified nurse aide (CNA) accountability record for bathing dated November 1-30, 2010 revealed the resident received a shower on November 10, 2010. Review of the bathing record from December 1-20, 2010, revealed no documented evidence the resident was bathed since November 10, 2010. The CCP, updated December 20, 2010, documented the resident continued to refuse bathing and shampoos, stating if she wanted a shower, she would take one. Review of the medical record on December 21, 2010, revealed no documented evidence the resident received supportive therapy; revealed no documented evidence the medication recommendation was implemented, and no documented rationale why the recommendation was not attempted. (As per the most recent psychiatry consult dated May 7, 2010). The surveyor observed the resident on December 21, 2010 at 11:50 AM, lying face down on her bed. On December 22, 2010 at 11:40 PM, the resident was observed sitting on the edge of her bed, eating her lunch. When the surveyor asked the resident how her lunch was, she stated she did not know what she was eating. The resident declined to talk to the surveyor further. At 12 PM, she was observed to be lying face down in her bed. In an interview with the CNA on December 22, 2010 at 12:10 PM, he stated he was familiar with the resident. He said the resident refused to bathe; she only wanted to have coffee, smoke, and sleep. The CNA stated the resident stayed in her room and refused care; she would come out to smoke, but refused activities. He said when the resident refused care, he reported it to the nurse. In an interview with the licensed practical nurse (LPN) on December 21, 2010 at 12:30 PM, he stated he was familiar with the resident. The LPN said the resident usually refused showers and when she refused, they re-approached her. He stated there was one CNA who could sometimes get the resident to wash up at the sink. The LPN said they tried to encourage her to go to activities, but she would get verbally aggressive if they were too persistent. In an interview with the registered nurse (RN) Unit Manager on December 22, 2010 at 12:50 PM, he stated activity and nursing staff were always trying to include the resident and encourage her to participate. The RN said it was his opinion that the resident was a sad individual, and stated the resident complained that no one helped her; then would swear at staff when they tried. The RN said the resident refused psychological services and agreed to only a tiny bit of medication. He said the resident had a friend she would socialize with, but that resident passed away several months ago. Since that time, the resident went back to her prior behavior of refusing care and activities, just spending time in her room. The RN Manager stated the psychologist re-approached her and the social worker also did. The RN said the resident accused the social worker of murdering 4 people and burying them in the swamp. He stated that because the resident was "competent", she could not be forced to do things or take medications. In an interview with the social worker on December 22, 2010, at 1:20 PM, she stated she just became familiar with the resident "1 or 2 days ago", when doing paper work for insurance. She stated she was unaware of other issues with the resident, and did not know she refused care. In an interview with the attending physician on December 22, 2010 at 1:35 PM, he stated he cared for the resident for approximately 6 to 9 months. He said the resident's biggest issue was "psychiatric"; and most of the time, the resident would not talk to him. The physician stated it was "pretty much the resident's baseline behavior", and was not acute. He said the resident had not been seen by psychiatry recently. The physician stated the resident was hard to engage; and per staff, this was her baseline since her admission to the facility (in 2009). He said he did not know why the the psychiatrist's recommendation (made in May 2010) were not acted upon. The surveyor interviewed the facility psychologist on December 22, 2010 at 2:30 PM. He stated he was involved with the resident in the past; and the resident refused medication. The psychologist stated it was hard to make recommendations because she refused everything, and would "not talk to mental health people." He said the resident was competent to make her own decisions of refusing medications. In summary, for Resident #2 who expressed: anger and adjustment difficulties, sadness of the loss of a friend, and feelings that her life "was not good", the facility: - did not implement her CCP interventions that specified the team would "check the resident for unmet needs; regularly assess discharge potential; and engage the resident in discharge plan of care. Team will continue to help resident adjust, or work with resident for safe discharge." - did not provide supportive therapy for her ongoing feelings of anger towards her placement in the facility and sadness over the loss of a friend. - did not provide a documented rationale for not implementing the medication changes ([MEDICATION NAME]) as recommended by the psychiatrist. 10NYCRR 415.12 (f)(1)